Thursday, May 28, 2015

Unity Farm Journal- Fifth week of May 2015

Spring and Fall are very busy days on the farm.   With each passing day in May, you never know what new task will appear.

On Saturday, Kathy and I drove to Western Massachusetts near the border of Vermont and New York to pick up our Russian “nucs”, the mini-hives used to start a new hive.   Russian bees are challenging (I’m not making this up) since they tend to swarm and take over territory.  They are unpredictable and hard to control.    Thus, we created a site for them to take over, called a swarm trap.   We mounted a 10 frame deep hive with wax and lemon grass extract (a bee attractant) on one of our 8 foot fence posts.   If the bees swarm, they are likely to find this new home, making it easy to put the bees in a new hive.      Here's what a Russian nuc looks like.

The bees are busy gathering nectar from our 15 acres of wildflowers.    Here's a glimpse of the bees on wild honeysuckle.

This week one of our roosters, Lucky, disappeared.   He was a fierce defender of our hens.   I found a collection of his feathers in the deep forest, near coyote droppings.   He gave his life to protect his women.  Thanks Lucky.

Just as the West Coast has had water issues, the Spring in New England has been dry, windy, and problematic for growing crops.  We’ve had to use our stored water - the snow melt from this winter now in our local aquifer, to keep our orchard healthy.

The hoop house continues to burst with vegetables.   I harvest 25 pounds a day for humans and animals on the farm.

Our state Farmer-Winery license arrived this week, so now we’re a Federal bonded winery and licensed by the state to produce wines of all kinds including hard cider and mead.   Next weekend we’ll be making Spiced Orange Mead.   I sterilized all the equipment in the cider house in preparation for the fermentation to come.   You’ll see our beverages available for sale soon!

The dogs have been groomed and the alpaca sheared, so everyone looks picture perfect.   Here’s a random family portrait of the creatures gathered in the barn.

We're very close to all our creatures.    There's nothing like a roll in the hay with a Great Pyrenees.  I'm 6 foot 2.  Shiro is 6 foot 5 end to end.   Our weights are identical.

The weekend ahead includes mushroom inoculation, mead making, planting, harvesting, and mowing meadows.     It's joyful work!

Wednesday, May 27, 2015

Interoperability and the Trough of Disillusionment

Every technology has an adoption journey.     The classic Gartner hype curve travels from a Technology Trigger  to the Peak of Inflated Expectations followed by the Trough of Disillusionment. It often takes years before organizations reach the Slope of Enlightenment and finally achieve a Plateau of Productivity.

Have you noticed that Congress and the popular press have entered the Trough of Disillusionment for EHRs and interoperability over the past month?

Congressional staffers writing the 21st Century Cures bill (which is not yet law) seem to have concluded

1) we don¹t have interoperability (although no one is sure what exactly we have and do not have)
2) therefore we need more standards and that will solve all the business, political, and policy barriers to health information exchange
3) The Health IT Standards Committee must not be doing a good job because there are not enough standards
4) Therefore we should disband it and create a new politically appointed body
5) That new body will invent all the standards we need and then force vendors to stop their information blocking behavior (whatever that is), enabling precision medicine

USA Today, in one of the most one sided articles I’ve read, confuses ACA and HITECH, ignores the data about EHR adoption/health information exchange and concludes that EHRs “don’t talk to each other”, whatever that means.

It’s time to take a step back, define our requirements, examine our current state, and then focus on closing any gaps we find.

I oversee 5,000 patient data exchanges at BIDMC every day.   50,000 patients view/download/transmit their data every month.   We’re in beta testing with apps using Apple HealthKit, connecting home devices, iPhones and our EHR.     We have numerous affiliates with bidirectional data exchange.    There are few technology limitations.  The real challenges are political and policy barriers.

The Direct protocol, although more complex than the RESTful methods used by Facebook, Amazon and Google that we should embrace, has provided a foundation for health information exchange across the country.    Below is a snapshot of the current Massachusetts State HIE (the Mass HiWay) connections to Health Information Services Providers (HISPs), creating thousands of connections among hospitals and eligible professionals nationwide.   Every week, some new practice or hospital comes knocking at the BIDMC door and within hours we can create a connection.

Interoperability is real.  Interoperability has a very positive trajectory.   Saying otherwise is oversimplifying the reality of ongoing good work in progress.

When confronted by naysayers, we have only three choices

1.  Give up and declare defeat
2.  Get angry, frustrated, and flustered by the negativity
3.  Move forward with gusto, identifying gap after gap, then solving them.   We eat the elephant of interoperability one bite at a time.

Over the past week, I’ve found myself setting aside my emotions.   I’ve redoubled my commitment to doing the right thing, hiring great people and broadly communicating the change processes needed to ensure more data is exchanged with more people for more reasons, while still respecting patient privacy preferences.

I’ve thought long and hard about the day to day criticism we hear from government, special interests, and various press resources.  We have to avoid being distracted by the politics of any given moment.  In  a year and half the federal government will change completely .  Every major political leader in healthcare IT has changed since 2013.

If we stay above the fray, work on interoperability one practice and one institution at a time, and toil diligently to enable new infrastructure such as record locator services/provider directories/quality registries, we will create a learning healthcare system that is better with each passing year.

So next time you encounter the Trough of Disillusionment about interoperability, do your best to educate stakeholders about the trajectory we’re on and the challenges we can overcome by focusing and working together.

Maybe we can all stand on a hilltop and sing "I'd Like to Teach the World to Interoperate (In Perfect Harmony)" celebrating our progress to date and highlighting the work yet to be done?

Thursday, May 21, 2015

Unity Farm Journal - Fourth Week of May 2015

I’ve always thought that shearing transforms a fluffy overstuffed alpaca into a creature from a Dr. Suess book (the Lorax?).   Below are before and after shearing pictures of the alpaca herd.

In May the temperatures at Unity Farm have varied from a high of 90F to a low of 32F.   At 90F, a fully insulated alpaca will be heat stressed.   At 32F, a sheared alpaca will shiver.   It’s always challenging to pick the right date to shear.     Our timing this year has been positive - the sheared alpaca were cool on the hot days.   The low since shearing was 38F, but the alpaca warm up quickly after sunrise.

Kathy and I inoculated 500 pounds of oak logs with Ganoderma Lucidum mushrooms (Reishi, Lingzhi).   After 2 years in the forest, the logs should yield harvestable quantities which we’ll make available fresh and dried.

The apples, plums, cherries, peaches, pecans, and paw paw trees are now fully leaved out and covered with flowers.   The bees are rapidly filling their hives with pollen and nectar.

In May, the work of the farm is largely planting and bee maintenance   I’ve harvested our winter crops and have busily planted potatoes, squash, pumpkins, tomatoes, beans, and cucumbers.   The hoop house raised beds have all been refilled with fresh compost and we’ll have a new round of crops ready to harvest in 60 days.

Kathy continues to work with the bees every day, expanding their hives, inspecting them for disease, and ensuring they have everything they need for successful honey production.   We’re expecting to gather 100 pounds of honey this year, leaving 80% for the bees to overwinter.

One of our chickens, Terra, is moving sluggishly.   She’s three years old and had an orthopedic injury last year (chased into a fence by a predator).    At the moment, there are no signs of infection, so we’re keeping her warm, fed, and hydrated.   We’ll watch her closely.

One of our wood racks was knocked over, likely by a coyote chasing a guinea fowl.   I’ll restock the quarter cord this weekend.

Speaking of guinea fowl, although we are a vegan/vegetarian household and do not eat guineas, they are popular in other cultures.   Here’s a menu from my recent trip to Eastern Europe.  Check out the second main course.

This weekend I’ll continue planting, helping Kathy build bee equipment, and spend time with all the creatures of Unity Farm, basking in the perfect weather of Spring.

Wednesday, May 20, 2015

The May 2015 HIT Standards Committee Meeting

The May 2015 HIT Standards Committee focused on an in depth review of the ONC Notice of Proposed Rulemaking, with the goal of providing guidance to ONC by June as to which standards should be included in final rule, which should not be included, and which should be identified as directionally appropriate for inclusion in future regulation.

The meeting began with the ONC announcement that the HITSC workgroups would be disbanded in June and replaced by focused task forces.

We agreed that focused task forces have been successful in the past, but a better process for organizational change would be for ONC to provide a set of goals/requirements and then engage the members of the committee in a discussion of the structure that optimally supports the strategy.

We recently redesigned the workgroups and at present, committee members are not sure what problem is solved by changing the way we work.    As Petronius Arbiter said in 27 A.D., we have to avoid change purely for the sake of change as this creates frustration

 “We trained hard—but it seemed that every time we were beginning to form up into teams we were reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing, and what a wonderful method it can be for creating the illusion of progress while actually producing confusion, inefficiency, and demoralization.”

As a next step, I hope ONC follows the guidance of John Kotter in the management of change - build a vision, create a guiding coalition, convey an urgency to change, empower people to initiate the change, and sustain the change.    We will await word from ONC on the focus areas that will receive more agile guidance with a change in the HITSC structure.

For example, if the barriers to interoperability are lack of a consistent patient identifier, the need for enabling infrastructure such as a national provider directory with Direct addresses, the absence of economic alignment for data sharing, variations in privacy policy among the states, and restrictions on data sharing such as 42 CFR Part 2, then we should launch task forces to  focus the NPRMs on these issues, propose a voluntary national patient identifier,  architect enabling infrastructure for national directory services, encourage value-based purchasing models, and simplify heterogeneous privacy policy.   At the same time we’ll still need workgroups for security (which is an ongoing process not a project) and implementation/adoption (which serves as a check and balance for overly ambitious regulation).

We began the meeting with an overview of the 2015 Certification NPRM Comments from the Architecture, Services, and APIs workgroup by David McCallie and Arien Malec .   The take home message from their presentation is that many historical standards efforts can be accomplished more efficiently through the use of application program interfaces.

Next, we heard the 2015 Certification NPRM Comments from the Content Standards workgroup by Andrew Wiesenthal and Rich Elmore.   They proposed a list of content standards which are unlikely to be useful for the final rule (and maybe will never be ready for implementation).

Next, we heard the 2015 Certification NPRM Comments from the Transport and Security Standards workgroup from Dixie Baker and Lisa Gallagher.  They enumerated the standards which are considered mature by objective criteria and those which are not.

Next we heard the 2015 Certification NPRM Comments from the Implementation, Certification, and Testing workgroup by Cris Ross.  They made many observations about overly burdensome requirements and their most welcome recommendation was no requirement for automated numerator recording of any measure where to do so would require additional clinical documentation that is not necessary for patient care. This has been the biggest factor in creating inefficiencies in EHR use.

Finally, we heard the 2015 Certification NPRM Comments from the Semantic Standards workgroup by Jamie Ferguson, Becky Kush, Mitra Rocca, workgroup and Eric Rose.  Their key point was that actual code values should not appear regulation - instead the regulation should point to vocabulary authorities for the details.

At the moment, there are multiple events creating anxiety in US  healthcare IT policy making - the 21st Century Cures Act (described in my morning blog), the Burgess Bill, and even the  Notices of Proposed Rulemaking (ONC and CMS) themselves.    It’s a time that requires intense focus and strong leadership.    The role of the Standards Committee is not to criticize the work being done by any group, but to suggest a path forward that minimizes burden while maximizing improved outcomes.   At our next meeting, 10 members of the committee will reach their term limit and be replaced with new members, a great loss of institutional memory.  I look forward to guiding the standards effort for 6 more months until my own term limit is reached.

21st Century Cures Act

I’m in Washington today for the HIT Standards Committee and I will post the usual summary of the meeting this evening.  However, I wanted to post a morning preview of the opening comments I’ll make a the meeting.

We are in a time of great turmoil in healthcare IT policy making.   We have the CMS and ONC Notices of Proposed Rulemaking for Meaningful Use Stage 3, both of which need to be radically pared down.   We have the Burgess Bill which attempts to fix interoperability with the blunt instrument of legislation.  Most importantly we have the 21st Century Cures Act, which few want to publicly criticize.   I’m happy to serve as the lightening rod for this discussion, pointing out the assumptions that are unlikely to be helpful and most likely to be hurtful.

The interoperability language to be included in the 21st Century Cures Act would sunset the Health IT Standards Committee while a new “charter organization” would help define the standards of interoperability.

Under the latest language, which was revised over the weekend and yesterday, electronic records must meet those interoperability standards by Jan. 1, 2018 and face being decertified by Jan. 1, 2019 if they don’t.

The bill would also require EHR vendors to publish their application program interfaces. Vendors must also publish fees to “purchase, license, implement, maintain, upgrade, use or otherwise enable and support” their products.

There is no provision mentioning the sharing of substance abuse treatment records, which Rep. Tim Murphy said last week he was working to include. Congressional staffers said the version the House Energy and Commerce Committee marks up Wednesday may still be changed before a floor vote, which is expected sometime next month.

It does not make sense to officially sanction a “charter organization” and seed it with $10 million, creating yet another player in an already crowded field of groups working on interoperability.  I agree that coordinating the standards development organizations makes a lot of sense -- why not just direct ONC to create a permanent Task Force that reports to the HIT Standards Committee, and let ONC support it out of existing resources?

The drafts have other significant issues

“standards to measure interoperability” –  I have no idea what that means.  I suggest that ONC create and report outcome measures that require interoperability rather than trying to measure the process of interoperability.  With Meaningful Use Stage 2 we experienced the failure of process measures to truly measure interoperability - transitions of care sent from and to the same organizations, transitions of care sent to an outside organization then thrown away.

“information blocking” - I believe this concept is like the Loch Ness Monster, often described but rarely seen.   As written, the information blocking language will result in some vendors lobbying in new political forums (Federal Trade Commission and Inspector General) to investigate every instance where they are getting beaten in the market by other vendors.  The criteria are not objective and will be unenforceable except in the most egregious cases, which none of us have ever experienced.

“De-certification” makes no sense.  Every provider would have to be granted a hardship exemption, so what is the point of the decertification?

So, how do we accelerate interoperability?

1.  Make Meaningful Use and certification more manageable by narrowing its scope but tightening its enforcement.  Encourage and expand value-based purchasing initiatives and sunset Meaningful Use as quickly as possible. Meaningful Use/certification should be used to lay the foundation ecosystem, but value-based purchasing is what will transform health care.

2.  ONC should  focus/narrow the number of projects it is executing simultaneously

3.  The Role of ONC should be  certification, safety, alignment of Federal agencies, making available data to support nationwide interoperability (such as NPPES/PECOS data for provider directories), and creating transparency by disseminating market information.

4.   Aggressively clean up privacy/security heterogeneity.   We need to get alignment of state laws.  We need to remove barriers to patient identity management.  We need to get rid of arcane Federal laws such as CFR 42 Part 2.  This will require bold leadership and a significant effort.  It won’t lead to political career advancement, but interoperability will be enabled and it will improve outcomes for patients over the medium- to long-term.

5.    We need a full time leader at ONC once Karen DeSalvo is confirmed as Assistant Secretary of Health

Throughout my life, I have tried to be a neutral convener without an agenda.   I hope the industry realizes that my observations above are not meant to be emotional or dogmatic.   My only self-interest is to make a difference and prevent poor legislation and regulation from doing harm.

Thursday, May 14, 2015

Unity Farm Journal - Second Week of May 2015

While I have been traveling in Eastern Europe, Kathy has been busy with bees, alpaca, and the daily duties of running the farm.

There have been many articles about accelerating bee deaths/colony collapse disorder.

On our organic farm, there are no pesticides, herbicides, or significant stressors for the bees.   We keep them warm by having south facing hives painted in dark colors.   We provide them extra nutrition - pollen and sucrose during late fall and early spring.   We use minimal medication - oxalic acid treatment in Fall for Varroa mites and fumigilin B for nosema (bee dysentery) control.

The results have been promising.   We started one of the worst New England winters in history with 11 hives and end the winter with 7 hives.   2 of our queens have overwintered for two years.

In spring we have split 3 of hives and purchased a few new nucs.

As of this week we have 6 hives at the farm plus 2 nucs.   We have 6 hives set up on properties in surrounding towns.

By Summer we’ll have 12 hives at the farm and 8 hives off the farm, creating a very strong pollinator workforce.   The apple trees are all blooming at Unity Farm, so they are ready for pollination.

Yesterday, Kathy supervised the shearing of all the alpaca and llama.   The professional shearer was able to complete to the entire herd in 2 hour, taking off their winter coats in a single piece.    I’ll post before and after pictures next week.

One of the challenges of travel (and I really try to minimize overnight travel) is that the farm is filled with complex equipment and systems.  We have extensive water management and irrigation systems.  We have sophisticated heating/cooling systems for all the buildings.  We have a 400 amp electrical system backed up by generator.   In effect the farm is like a small city for 100 inhabitants.     Although I have maintained every system and replaced a great deal of the infrastructure, the heating/cooling systems are 22 years old and still vulnerable to breakdowns.    As a farmer, I know to conserve capital and avoid purchasing too much too fast - that’s what causes economic stress for small farmers.  The heating/cooling system replacement is likely a 2016 project, since our big improvement in 2015 will be replacing the driveway/paved areas of the farm (which are also 22 years old).   One day after I left for Eastern Europe, the primary ventilator fan for heating/cooling the house failed.   The weather station also failed but that is IP connected and I was able to reboot it/reconfigure it from Eastern Europe.   However, our heating/cooling infrastructure is no IP connected so I had to diagnosis it manually with Kathy serving as my eyes, ears, and fingers.   It’s clear that that relay failed and since the ventilator was manufactured in 1993, the parts are only available on eBay.   I was able to locate the needed part and Kathy purchased it, so it will be ready for my repair work when I land in Boston in 13 hours.

The work of a farmer is never done - keeping the bees healthy, the alpaca/llama cool in summer/warm in winter, and the systems of the farm running is immensely satisfying.

It also gives me a context to experience the traditional arts of other cultures.   Here’s a few photos from the Latvian Natural History museum - Eastern European bees, traditional bee keeping and even an alpaca (imported to Latvia from South America).

As I posted yesterday, I can imagine running a castle and farmlands in Europe, and I really have an affection for Eastern Europe,  reinforced by a visit with Latvian IT leaders at the American Embassy last night (pictured above), but I look forward to returning to my own “castle” in Boston tonight.  

Wednesday, May 13, 2015

Dispatch from Eastern Europe

I’m in Riga, Latvia today at the request of the Office of the National Coordinator, explaining the HITECH act and the US national HIT strategy to experts in the European Union 2015 EU-US eHealth/Health IT Cooperation Assembly.

My mother was born in Latvia and left in the 1940’s, so 2015 seemed like a great opportunity to visit her birthplace together and have a Latvian translator at my side.  

We’ve walked 15 miles each day this week, exploring Old Riga, Central Riga, the countryside, the national forest, and the waterways of Latvia.  I think I have exhausted her.

My father was from the Czech Republic with family roots in Poland and Germany.

My mother’s family roots are in Poland and Russia.

Walking around Eastern Europe I have the distinct sense that I’m with my people.

They have a love of mushroom hunting, I’m one the US experts on wild mushrooms.

They have a love of beekeeping and honey production.   I’m a beekeeper.

They have a love of nature and a spiritual link to the land/seasons.   As a farmer, alpinist, and believer in shinto, I feel the same.

The local traditional foods - pickled vegetables, soups,  high fiber breads, freshly brewed local beer, and seasonal wild berries, are my soul cuisine.

Although it would be very difficult to maintain my Harvard appointment, my commitment to my staff, and my farming duties in New England, there is an allure to living a bucolic life in rural Eastern Europe.     Maybe a 13th century castle?

A great week with my mother and sharing the US eHealth experience with others.

Many memories were made and great people met, but for now, I have miles to travel and promises to keep in Boston.

Thursday, May 7, 2015

Unity Farm Journal - First Week of May 2015

We’re now in the middle of Spring mushroom season.   Shitake subtypes like Westwind, Double Jewel, Snowcap, WR46 and WW70 have been particularly productive.   The bulk of our mushroom production is in the Fall, but having two fruitings per season really helps our mushroom business.

At present, we have only 10,000 pounds of oak in Shitake production. In the western part of Massachusetts, one commercial Shitake supplier has 450,000 pounds of oak logs growing mushrooms.  This year, Kathy and I will add an additional 10,000 pounds of oak for new Shitake varieties, Nameko mushrooms, and Gandoderma Lucidum (Reishi/Lingzhi).    We’ll process 1000 pounds of logs every weekend for the next 10 weeks.   Here's this weekend's batch

This week we’ve had unseasonably warm weather.   We've finished planting the heat loving vegetables - tomatoes, cucumbers, eggplant,  squash, and pumpkins.   All our watering systems (micro sprinklers connected to our well) have been keeping the young plants moist and we've cranked up the sides of the hoop house to avoid drying out the 16 raised beds.

While I was in China, Kathy and a local excavator completed the trenching of the electrical line to the cider house.    When I returned, Kathy and I ran 250 feet of burial cable through the conduit and I completed the wiring to 2 lights, 2 plugs, and 2 switches.    With electrical in place, I was finally able to use the shop vacuum to fully clean the inside of the cider house,  removing all the saw dust and debris from its original construction.    Our efforts were just in time - the state inspector visited this week as part of our Massachusetts licensure as a farmer winery (we're already a Federal bonded winery).    As soon as the inspector issues the certificate, we can begin selling our hard cider at the farm.  The next step will be a farmer's market permit for selling Unity Farm ciders at local farm stands.

Kathy’s bee work continues and this weekend we'll receive 4 “nucs” of Buckfast bees  (in addition to the 2 “nucs” of Russian bees arriving next week).    She has set up 6 new hives in Holliston, Wellesley, and Medfield as part of our honey production and queen breeding program.    With 18 hives and nearly 200,000 bees, Unity Farm will have a good quantity of honey to sell this year.   Next week I'll be in Russia from Monday-Thursday.   I can only hope that my blog entries about buying Russian "nukes", does not impact my immigration status.

While I was in Shenzhen, China last week, I sent Kathy a photo of the airport terminal, which is a perfect model of a bee hive.    Just imagine the bees that built it!

Wednesday, May 6, 2015

Dealing with Difficult People

All of us interact with difficult people from time to time.    Rather than have a dialog, difficult people make demands.  Rather than objectively analyze a situation, difficult people subjectively render opinions as if they were fact.   They often put the needs of the few ahead of the needs of the many.

How can you succeed when dealing with difficult people?  

Should you challenge their world view and hope that yelling at them will work?  Nope.  Active listening is the answer.

When an unreasonable person asserts an opinion that I know not to be true, I do not argue with them.   Instead I ask them to express their point of view more fully.    I then replay back to them what I heard

“I’ve heard you describe the functionality you desire.   The most important features are A and B, followed by C.    In the future you’d like D and E, but it’s too early to provide those design details.     It seems that a 2015 go live of A and B will be very helpful to you.   In 2016, adding C would really help”

Very often, I can turn a confrontation into a phased, incremental improvement plan.

There are times when difficult people are irrational, leading to a breakdown of the active listening technique i.e.

“Everything is a priority and you must do everything instantly.  Incremental progress is not helpful”

Again, arguing or negotiating with such a person is rarely helpful.   If my first attempt does not succeed, I suggest that another member of my leadership team also speak with the difficult person to gather more information.

People want to be heard.   I find that listening, acknowledging their opinions, mobilizing other team members, and then following up resolves 99% of all conflict.

In our modern era, top down, formal top down authority does not work in any industry.   For all that we want to be able to resolve conflict by fiat, listening is much more effective.