The Roles I Play

As 2014 begins, I marvel at the evolution of the CIO role from 1997 to 2014.   Gone are the days when my role was to serve as technical expert, configuring web servers, optimizing data bases, or simplifying code.   Gone are the days when product decisio nmaking depended on software architecture expertise to ensure scalability, reliability and security.   Gone are the early wins of the "bold moves" like replacing Lotus Notes with Exchange, Novell with NT, Sybase with Microsoft SQL, and client/server with web applications.

Here are a few examples of the roles I play today from the past few weeks

1.  Rethinking a challenging project by ensuring all stakeholders understand the key roles/responsibilities assigned during project formation i.e.

Defining the business champion
Defining the executive sponsor
Defining the role of IT
Defining the role of the project manager
Defining the support model
Defining the responsibility for creating, managing, and maintaining interfaces
Assigning responsibility for workflow/process definition
Assigning responsibility for vendor relationship management
Writing the governance committee charter
Defining the communication plan for internal and external customers
Defining unit testing and integrated testing responsbilities
Defining the training/education plan

2.   Convening local government and provider stakeholders to agree on a single approach for public health reporting that aligns meaningful use stage 2 requirements, healthcare information exchange timelines, and affordable care act planning.   We needed consensus on scope, timing, and technical details so that local government efforts are complementary rather than competitive to the regulatory "must dos" of 2014

3.  Presenting the BIDMC Enterprise IT strategy to senior leaders of the hospital and professional groups, so that all stakeholders understand the options, the decisions make thus far, and linkage between business requirements/IT tactics.

4.  Serving as master of ceremonies for the statewide health information exchange public demonstration, ensuring all involved institutions were showcased to highlight their strengths.

5.  Assisting with the development of new policies and procedures such as those involving privacy, healthcare information exchange and use of social media in healthcare

In 2014, the my work role has evolved to convener, communicator, mediator, navigator, and load balancer instead of technician, architect, programmer, informatician, and clinical expert.    Not that the evolution is bad.  In the modern era, we all have about 5 careers in our lives.  What's amazing to me is how many careers I can have without changing my position as CIO!

I recently wrote a column for Information Week, Boiling the Frog describing some of the challenges all CIOs face as their roles evolve.   As we begin 2014, I have the recovery time afforded by the holidays behind me and I'm approaching my role with new optimism.   The chaos and stress of 2013 is behind me.    I'm ready to thrive as I focus on using my evolving skills to make those who report to me as successful as possible.

Over the holidays I completed two books which will be published in the next few weeks, codifying everything I've learned in my CIO roles over the past 20 years.   One is a 400 page edited, revised, and indexed reflection on the themes of my blog.    I'll be doing a book signing at HIMSS.  The other is a 250 page fictional thriller co-written with a prominent Italian healthcare system CIO and containing many elements inspired by the IT events I've experienced over the past few years.   More to come as they are published in paper and e-book form.

Building Unity Farm - Thinking about Automation

Every year at Unity Farm, I move 10000 pounds of manure, 10000 pounds of logs (18 inch segments), 10000 pounds of wood chips, and thousands of pounds of snow.    I've done this to date using a hand cart and wheelbarrow.    I turn 52 in a few months and its time for automation.

But, what's the ideal device?   We have hills, forests, meadows, mud, ice, and grass.

A tractor such as the Kubota B3200HSD seems reasonable with industrial R4 tires that provide traction without too much damage to underlying soil.   John Deere offers a competitive model of tractor, the 3032E.

However, many of the trails at Unity Farm are narrow and the manure access is via a crusher rock access path about 5 feet wide.  Are there alternatives?

Many have recommended a compact track loader such as the Bobcat T110.

Others have recommended the Terex PT30

Track loaders provide maneuverability and good hill climbing capabilities, but they can be rough on grass.

My answer - I have to experiment with each machine.    Since they vary in price from $16000 to $25000 (0% financing for 5 years may be available), it's best if I "test drive" them.

For $200 per day, I can rent these devices from local dealers.   I can move manure, wood, rocks, and mulch.   I can run them up and down hills in a variety of conditions.

To me, the device design/engineering is important but access to dealer service is also critical.

The Kubota/Terex dealer is 12 miles away.  The Bobcat dealer is 35 miles away.   The John Deere dealer is 35 miles away.

I'll report back on my experiments with moving, hauling, and transporting around Unity Farm.   I welcome input from others on comparing Kubota, John Deere, Bobcat and Terex.

The Next Phase of Healthcare Information Exchange

Today, Massachusetts Governor Deval Patrick will launch the next phase of healthcare information exchange (HIE) in Massachusetts - “Commonwealth Interconnected:  Mass HIway Query and Retrieve”

In Phase 1 of our state HIE project, we focused on the Meaningful Use Stage 2 Direct protocol, enabling transition of care summaries, public health reporting transactions, and labs to flow over a state operated secure infrastructure.

In Phase 2, we solved a much harder and more complex problem - the pulling of records in real time from physician offices and hospitals where patients have opted in to disclose their records to other caregivers.

This required the engineering of several components
*A state wide master patient index for patients who opt in, storing name, gender, date of birth and other demographic data elements
*A state wide consent registry indicating the medical record numbers and locations where patients have opted in to disclose their data to caregivers
*A portal which enables providers to securely login and view patient medical record locations
*A viewer which enables secure retrieval of medical records from organizations which support real time data display
*An electronic medical record request system for those organizations which support a request/release by the medical records department workflow.
*Full audit trails of all activity - an accounting of disclosures

Today a multi-organizational team will demonstrate an Emergency Department visit by a febrile, confused, elderly gentleman.   His records are scattered over many hospitals and clinician offices.   Treatment in an emergency room is accelerated, more aligned with patient/family care preferences, and is safer with more information.   We'll demonstrate how a single institutional record based on one episodic visit can be very different than a lifetime continuous record which includes the entire patient experience with healthcare.     We'll show several near misses with diagnostics and therapy that could have caused harm, increased expense and reduced quality.

Today is the launch of the service.   The state's master patient index and consent registry (collectively called the relationship locator service) will be populated as patients consent to be included.   57 organizations including providers, public health, health plans, local HIEs and clinical registries are already part of the Massachusetts HiWay and all will be working hard in 2014 to expand the use of the new services.

I can imagine a day in the next few years, when all patients in the Commonwealth, with their consent, benefit from secure, coordinated care.    My mother suffered a major medical error in California because of inaccessible primary care records.   I truly believe that my 20 year old daughter, attending Tufts University, will see significant reduction in preventable harm in Massachusetts during her 20's.

Let the safety begin!

Baby, It's Cold Outside

For those who not have experienced Winter Storm Hercules , it's currently -10F at Unity Farm (not wind chill, that's -15F).    We have 10 inches of new fallen snow.

As I've written about previously, all the animals have protection from wind and water.  Wall mounted heaters are protecting them from frostbite.      At dawn we gave the alpaca and llama large bowls of alfalfa mixed with molasses.   The chickens and guinea fowl ate hot oatmeal mixed with dried cherries.   The ducks got a warm duck soup of chopped greens and warm water.    The dogs got an extra helping of their favorite dog food.   The rabbit got a very sweet banana.

Here are a few photos at -10F from Unity.    Yes, an iPhone 5S works well at that temperature, although fingers using the phone do not last long.

I added bricks to the top of the bee hives to prevent the covers from blowing off.   We added sugar feeders to the inside of each hive and replaced the hive opening with a very small "winter" front door.  A capping of snow insulation is keeping them warm.    

We refilled every bird feeder, ensuring our juncos, chickadees, bluebirds, wrens, finches, titmice, woodpeckers, cardinals, and nuthatches have maximal nutrition.

The cider house is keeping all the apple picking and beekeeping equipment safe from the elements.

We shoveled all the paths and gates for easy access to the coops and paddocks.

The hoop house is a balmy 28F, keeping our winter vegetables growing by trapping the heat of the sun.

The blowing snow drifts created Zastrugi in the orchard 

The pastures are covered with a blanket of snow.   After 2 years of moving snow, mulch, and manure with a hand drawn wagon, I'm finally considering a tractor.

Shiro, our 120 pound Great Pyrenees male, has very big paws for scrambling through snow.

The duck pond is frozen and covered with snow, although the water is still circulating below the surface.     The ducks bathe in their 50 gallon stock pond that is heated to 40F.

We dug out the garden shed to access all our snow management tools.

Shiro kept a close eye on everything during the storm.

We removed the roof from the mushroom house to keep it from collapsing under the weight of ice and snow.

We have three mushroom "laying" yards where fruiting logs are kept for harvest.   At this time of year, the only creatures exploring the laying yards are deer, rabbits and foxes.

The dogs are begging for a run on the trails, but at the moment only deer are running through the 10 inches of loose powder.

I've split 8 cords of wood for heating this winter.   We'll use half a cord during the duration of Hercules and the freezing days to follow.

Stay warm!

Building Unity Farm - Making Mead and Cyser

The entire family visited Unity Farm for the holidays.  After all the gift giving, merry making, and
yuletide time by the fire was over, what should a family do at a farm with apples, honey, fermentation equipment (there's a basic chemistry lab in the cider house), spring water, and microbiology know-how?   Make mead of course!

Mead was the earliest fermented beverage created by man - evidence of honey and fermentation products begins about 9000 BC.   Mead figures prominently in Hindu writings, the work of Aristotle, and the Old English poem Beowulf.  

There's a new vocabulary to learn when deciding how to make Mead.

"Show" Mead - a higher alcohol, full flavored mead made with more honey and less water
"Small" Mead - a lower alcohol, lightly flavored mead made with more water and less honey (Queen Elizabeth the First enjoyed a very dilute mead)
Melomel - mead with added fruit or fruit juice
Pyment - a melomel made with grapes and often herbs.   You could call it a honey-fortified wine
Cyser - a melomel made with apples.   You could call it a honey-fortified hard cider
Zythos or Braggot - a mead fortified with malt.   You could call it a honey-fortified beer
Morath - a melomel made with mulberries
Metheglin - a mead made with herbs or spices.   The name means "Mead of the Glen".   Some believe it is the root of the term "medicine"
Rhodomel - a metheglin made with roses

At Unity Farm, we tend to prefer our beverages fermented dry.  We often create both sparkling and still versions of our beverages, but I only make still mead after a bad experience with exploding bottles as a mead maker in my 20's.   Here's the approach we used during the holidays:

Unity Farm Mead
 3 quarts water from our 600 foot deep well
 3.5 cups Unity Farm Orchard Honey (wildflowers and clover)
 1 teaspoon acid blend (citric/malic/tartaric acids)
 5 grams Redstar Pasteur Champagne yeast
 6.25 grams Go-Ferm yeast nutrient in 125cc's of 110F water
 10 grams of Fermaid-K

Heat the water to 160F, add the honey and acid blend.   Simmer for 10 minutes and do not boil.   Skim any foam from the top.   Pour into a 2 gallon sterilized fermenter (we use food grade buckets with a drilled lid and airlock, pictured above).    Take a ph or specific gravity measure if you wish.   Our 12/29/13 batch had a specific gravity of 1.090 and a ph of 3.43, giving us a potential alcohol level of 12%

Add 6.25 grams of yeast nutrient to 125cc's of 110F water.    At 104F add the yeast and wait 15 minutes.   Cool 100cc's of the honey/water solution to 104F and add it to the yeast solution.   Wait 15 minutes.   The resulting yeast solution will be frothy with new yeast growth.

When the honey/water solution in the fermenter is 104F add the yeast solution.    Place in a room with a constant temperature in the low 60's for slower, more flavorful fermentation.

After 1 day, add 5 grams of Fermaid-K

After 1 week, add 5 grams of Fermaid-K

After 2 weeks, rack the solution with a racking cane into a sterilized gallon jug and seal it with an airlock.  Leave very little air space  in the jug (1/4").  Top up with water if necessary.  After 2 months, sterilize the mead with 50 parts per million of potassium metabisulfite, then bottle and age for 6 months before drinking.

Unity Farm Cyser
 1 quart water
 2 cups Unity Farm Meadow Honey (wild asters and japanese knotweed)
 1 teaspoon acid blend (citric/malic/tartaric)
 1 cup black tea (steeped 3 minutes at 200F)
 2 quarts Unity Farm unfiltered Apple Cider (made from 11 types of apples)
 1/2 teaspoon pectic enzyme
 5 grams Redstar Pasteur Champagne yeast
 6.25 grams Go-Ferm yeast nutrient in 125cc's of 110F water

Heat the water to 160F, add the honey, acid blend and tea.   Simmer for 10 minutes and do not boil.   Skim any foam from the top.   Pour into a 2 gallon sterilized fermenter.    When the mixture has cooled to 110F, add the cider and pectic enzyme.

Take a ph or specific gravity measure if you wish.   Our 12/29/13 batch had a specific gravity of 1.085 and a ph of 3.56, giving us a potential alcohol level of 11.3%

Add 6.25 grams of yeast nutrient to 125cc's of 110F water.    At 104F add the yeast and wait 15 minutes.   Add 100cc's of the honey/cider/water solution to the yeast solution.   Wait 15 minutes.   The resulting yeast solution will be frothy with new yeast growth.

Add the yeast solution to the fermenter.    Place in a room with a constant temperature in the low 60's for slower, more flavorful fermentation.

After 1 day, add 5 grams of Fermaid-K

After 1 week, add 5 grams of Fermaid-K

After 2 weeks, rack the solution with a racking cane into a sterilized gallon jug and seal it with an airlock.  Leave very little air space  in the jug (1/4").  Top up with water if necessary.  After 2 months, sterilize the mead with 50 parts per million of potassium metabisulfite, then bottle and age for 6 months before drinking.

Although we've not enjoyed the flavor of commercial melomels, we will create our own blueberry, raspberry, and elderberry melomels this summer when the berries are ready.

Mead is an acquired taste and you will want to experiment with different styles to find the right mead for you.   Hence I recommend 1 gallon batches that enable you to evaluate each recipe variation but not create an overabundance of something you'd prefer not to drink.

Happy mead making!

The Year That Was 2013

As the year drew to a close, I was interviewed by many trade publications about the key themes that shaped 2013.   Here's my own version of the notable events of 2013.

1.  Meaningful Use changed the EHR landscape
Regardless of your political affiliation, there is little debate that EHR adoption in the US achieved a tipping point in 2013.   Here are our Massachusetts statistics from the 2013 Massachusetts Medical Society survey

The current overall percentage of EHR use is 79% (N=201, CI=5.6) and 82% of those using EHRs have had access to this technology for more than 2 years. Extrapolated to the estimated 18,000 clinical physicians in the state, that would leave less than 3,500 clinical providers without access to EHR systems (3% of respondents indicating that they are no longer in practice).

Broken down by practice size adoption rates are:
1-9 Physician practices made up 66% of respondents and had an adoption rate of 75%
10-25 Physicians practices made up 13% of respondents and had an adoption rate of 96%
26-75 Physicians practices made up 6% of respondents and had an adoption rate of 100%
>75 Physicians practices made up 12% of respondents and had an adoption rate of 97%

2.  Healthcare Information Exchange developed great momentum
Meaningful Use Stage 2 and more importantly the Affordable Care Act motivated organizations to implement push (via Direct and HISPs), pull (via regional and state HIE activities) and view (among clinical affiliates) interoperability for care coordination and population health.   As a CIO, I'm no longer the lone voice driving interoperability top down, it has become a bottom up demand.

3.  Security and privacy became Board-level issues
Meaningful Use, compliance requirements, and enterprise risk assessments elevated security and privacy issues to top priority for many organizations.  CIOs are hiring new security staff, enhancing capabilities, and expanding budgets to address increases in threat sophistication and volume.

4.  Self built EHRs became increasingly rare
Partners Healthcare and MD Anderson adopted Epic.   Intermountain Healthcare adopted Cerner.  That leaves Beth Israel Deaconess and the Marshfield Clinic among the few healthcare organizations building applications to enhance innovation and reduce cost.    An unintended side effect of Meaningful Use Stage 2 certification criteria was that provider self built systems, niche specialty applications, and small EHR vendors all became rare.

5.  Innovation slowed as the regulatory combination of ACA, ICD-10, MU2, and HIPAA Omnibus rule dominated the agenda for IT organizations.

The work I've done on Natural Language processing, Google Glass, advanced analytics, workflow enhancement, and patient/family engagement was limited to nights/weekends and the strength of will of selfless volunteers who innovated outside the workday.

As Meg Aranow guest posted on my blog in 2011, the content of being a CIO in 2013 continued to be great, but the context became even more anxiety-provoking .   Demand exceeded supply, anxiety/tension escalated, and budgets became even more constrained (except for selected security/compliance projects, which are often seen as burdensome rather than beneficial by customers).  The holidays brought a welcome reduction in post traumatic stress disorder symptoms for many CIOs I know.    However, on the positive side, I've always felt that times of great struggle are opportunities for greatness.   We are living in the most transformative time for healthcare in the US, and the worsening CIO stress is just a side effect of accelerating change for all healthcare stakeholders.   I recently wrote about the mitigations we need to consider to get through each day.

Personally, 2013 was a combination of emotional highs and lows.   My father died in March.   My mother entered a new chapter in her life requiring resilience and new skills.  My wife's cancer is in remission although she still experiences the side effects of chemotherapy, peripheral neuropathies and muscle spasms, that impact her activities of daily living.   My daughter thrived at Tufts University in 2013, maintaining her own apartment, living independently, and viewing the world with increasing sophistication.

Unity Farm continued to grow in 2013 with 11 chickens, 10 ducks, 29 guinea fowl, 11 alpaca, 1 llama, 2 Great Pyrenees Mountain dogs, 3 cats, and 1 rabbit in perfect health.  2013 was the year our orchard was born, the cider house was built, our duck house/pond was created, and we established a regular routine for efficiently managing all 15 acres of woodland, pasture, and wetland.   We obtained various licenses and certifications to begin selling our jams/honey/cider/mushrooms/vegetables and learned a great deal about producing organic, handcrafted products.

The combined responsibilities of leading IT for a growing ACO, assisting several countries with IT strategic planning, working on US national standards, championing state healthcare information exchange adoption, and being a Harvard Professor strained my endurance at times, especially early in the year when I made 5 visits to California around the time of my father's death.   Trips to China, Japan, Taiwan, and London were all important, but required boundless energy to ensure my day jobs were fully supported while I was half a world away.   2014 will have much less travel than 2013.

I turn 52 in a few months and as I reflect on the year that was 2013, I can say it was one of the most difficult on the journey thus far.  However, at the end of the year I feel the trajectory heading into 2014 is right.   The healthcare environment will still undergo tectonic shifts but my family, friends, and colleagues will make it navigable.    I will reaffirm my quest for equanimity in all difficult situations, my veganism, and my balance of work/farm life.    May 2014 be happy and healthy for all of you and enable you to make a difference.

Building Unity Farm - A White Christmas on the Farm

It's Christmas at Unity Farm and the temperature outside is 12F.   All 100 animals are fed, watered, and their living quarters are cleaned.

The orchard and cider house have been put to bed.   I racked the last 60 liters of our fermented cider into three 20 liter Spiedel tanks and inoculated two of them with malolactic bacteria (Oenococcus oenii) to soften the acids and round out the flavor.   We'll bottle still and sparking cider in the Spring.

The hoop house is filled with salad greens, thriving in the balmy temperatures of cold frames and planting blankets.   The soil temperature of our 15 raised beds is between 50-60 in winter.

The ducks are now 12 weeks old and have begun to venture beyond their duck pen and spend the day with the chickens and guineas.

The guinea fowl have decided that the duck pond is a spa and enjoy washing their feet in the running water.

The mushroom logs are dormant in the cold but the oyster and shitake cultures within them continue to thrive.   We've removed the roof of the shade house so that it does not collapse under the weight of snow and ice.

The farmhouse is the focal point for entire family - my wife, my daughter, my mother, my daughter's boyfriend, his parents, and my father in law are all gathered for a vegan feast.

A cheery fire is burning in the heath - a mixture of ash and maple woods from the 10 cords I've cut and split this season.

2013 has been a year of high highs and low lows.   This is the first Christmas without my father.   My wife's cancer is gone, my daughter's semester at Tufts was very successful, and all the creatures at Unity Farm are thriving.

In a world with decreasing resources, an increasing population, and accelerating change, there's a tendency to lose civility.  My own experiences this year have reinforced the importance of maintaining equanimity in the face of adversity.   As the year draws to a close, there is no regret for anything I've done or not done, professionally or personally.    The holiday season in 2013 will be an excellent wrapper around one of the most tumultuous years of my wife.

As 2014 approaches, I can only hope that our happiness persists, regulatory burdens diminish, and breakthrough innovations become our standard work.

Happy Holidays to all!