Unity Farm Journal - Third Week of February 2015

What happened to the term “polar vortex”?   Are we now beyond it into something more severe?  Unity Farm has not had a day above freezing or a night above the single digits (often negative single digits) in over a month.    The most simple acts - walking to the hoop house, stacking supplies, and shoveling manure - require full alpine climbing gear.

Despite my hours in the Terex front loader creating a grand canyon of snow, it’s difficult to keep every aspect of the farm running.    To understand the scale of our storms, imagine filling Patriots Stadium to the brim 90 times - and that is just the amount of snow removed from downtown Boston the past 30 days.     The entire public transportation system will be shutdown/on limited schedule for the next month.   And another storm is on the way for this weekend.

“Snow rage” abounds as commutes are measured in hours per mile, not miles per hour.

I can only hope that this winter does not become a standard experience.   If it does, then the farm’s next capital purchase will be the snowblower attachment for the Terex.

No more, Mr. Nice Guy.  A properly equipped Terex can blow 100 tons of snow per hour, 45 feet into the air.     The idea of cruising along the farm roads and trails in the warmth of a the Terex cab, listening to Japanese flute music while slicing through 7 foot snow drifts sounds very appealing.   I’ll keep it in mind for next season.

This year I split 8 cords of wood to keep the fireplaces toasty.   My morning routine now consists of caring for the animals then hauling a hundred pounds of wood indoors so that it can thaw before nightfall.   Who could have known that the neatly stacked wood would be 7 feet under non-melting snowbanks for the month of February?

I’m doing my best to offer grain/seeds to all the squirrels, turkeys and deer trying to survive the winter.   How does a squirrel navigate a 7 foot snow pack?  They must have talked to the moles, because we now have squirrel tunnels to the feeding areas.

This Sunday may include wintery mix - ice, snow and rain.    The snow on the roofs currently weighs 5 pounds per cubic foot, but wet snow will weigh 21 pounds per cubic foot.   I’m using a 20 foot snow rake to clear the sheds, barn and house before it comes icy concrete.

One advantage of this much snow is that it makes filling the bird feeders much easier.  The 8 foot feeders are now at ground level.

 Although the creatures are feeling claustrophobic, they are well fed and watered, which is key to their winter survival.    I've carved a "duck highway" and covered it with straw, so they have a yellow brick road between the warm of their house and the extra food/water we've put out for all the birds.

Despite the hardship, the alpaca and llamas are getting dedicated attention.   As one Alpaca farmer in New York posted

"I am head waiter at the Alpaca Fine Dining Restaurant located here in Western New York. For today's offering, we start with a fine appetizer of select grains served with a finely chopped, alfalfa chaffee hay salad. For our main course we offer delicious second cut orchard grass beautifully arrayed in our special "hay" feeders. To complement this, we offer slightly warmed fresh well water. I can expect a 20% tip of artfully arranged (and I might add frozen solid) alpaca beans. All's right with the world!!"

Mobile Applications Update

I have long believed that social networking concepts, mobile devices, analytics, and cloud are key tactics for the success of any IT organization.   We’re in an era as significant as the mainframe to PC revolution in which BYOD devices and apps are becoming the platform of choice.    Given the regulatory/compliance mandates for security, the need for auditability, and the need for provenance (can we trust the data?), implementing a mobile strategy in a healthcare environment can be tricky business.

Here’s an update on two projects we’re working on now that attempt to balance functionality with security.

We’ve written an iOS app that enables patients to connect their home devices with BIDMC clinical systems using HealthKit as middleware.

Below is a screen shots of the application in use.   My staff have been testing it with electronic scales that report weight to HealthKit.  

App users do a one time registration to give the BIDMC app permission to read values from Healthkit.  They also login to our Personal Health Record, Patientsite, one time to enable upload.  Then the App gets called by the iOS operating system whenever there is a new weight entry into Healthkit.  The new weight entries (since last successful upload) are automatically uploaded and the user gets a notification of success.

Here’s how the data appears in the BIDMC systems.   Each transaction is logged with a universal ID, date/time and provenance ensuring data integrity and traceability of each data element.

We’ll pilot the application and then enhance its usability based on lessons learned.   We’ll continue our work to determine what alerts/reminders are sent to clinicians, care managers, and family members based on variation in the data provided by home devices.    Weight changes can predict fluid retention leading to congestive heart failure exacerbations.    Blood pressure tracking can support personalized adjustment of medications.   Shared glucometer data can lead to better control of glucose over time.  Very exciting possibilities.

One of the downsides of BYOD is that smartphone photography can lead to privacy issues such as revealing clinical information inappropriately, should the photograph become available on a social network or publicly available website.   BIDMC is piloting a new camera created by Ricoh that uploads photos to the electronic health record and deletes them from the camera immediately, enabling photographs to be curated via the all the usual policy and technology controls surrounding the electronic health record.

If the pilot is successful, we can then change policy at BIDMC, requiring that purpose built, EHR connected, secure cameras be used for all clinical photography.   The combination of technology and policy should reduce risk.

We continue to explore options to make our workforce more mobile, procuring services that enhance productivity and usability while protecting security and safety.   More to come!

Snow Update from Unity Farm

In the past few hours, another 17 inches has fallen.   The temperature is 10F, but headed to -10F tonight.   We have 30 mph winds.

The creatures are warm and dry in the barn.   All the feeders and waterers are full.   I've picked fresh greens from the hoop house and given them to chickens, ducks, and guinea fowl.

How did I do this?

I put on my Mt. Washington climbing gear to exit the front door, where the snow level was higher than the door knob.      The snow in the paddocks is over 7 feet high.   The driveway piles are 10 feet high.   The bee hives and apple trees were completely submerged by snow drifts and I dug them out with my avalanche rescue gear.

Is this Unity Farm or the Ernest Shackleton expedition?

Unity Farm Journal - Second Week of February 2015

Every time I step outside at Unity Farm, I want to sing “Let It Go, Let It Go…” since the world around is clearly Frozen.  The icicles weigh more than 25 pounds.    The Prius "snowmobile" is only visible by looking for the side mirror.

We’ve had over  72 inches of snow in the past 3 weeks.   The top of the snow gauge is UNDER 3 feet of snow.    The weather has been in the single digits, so no melting has happened.   I’m 6 foot 2 and the snow drifts are now taller than me.

As an alpinist, I’ve climbed every peak in New England during winter.   I’ve taken an engineering approach to clothing, reducing heat loss caused by conduction, radiation, and convection.

My morning animal care and farm maintenance requires a polyester base layer, Polartec Power shield, vortex, my ice climbing boots, and thick nylon gloves/gaiters.

Walking a mile on the farm at the moment is harder than climbing Mt. Washington  in winter (the worst weather in the world).

The Terex front loader has been an essential tool since it enables me to create 8 foot high canyons of snow for the animals and to open up paths to buildings/supplies.   I’ve been using 10 gallons of diesel per week just to clear snow/ice.    We’re expecting another foot of snow today and there is no place left to put it, so I’m converting one of the pastures to a snow parking lot.

Llamas and alpacas live in the Andes, a dry/cold area.   They are comfortable with temps below zero, but really do not like navigating deep snow.   The Terex and the snow blower together have been enable to create paths and create areas for eating/sleeping outside the barn.    They spend storm days inside the barn, but have cabin fever, and want to run, which is difficult in 6 foot deep frozen quicksand.

Our chickens are bred for cold climates and do not mind chilly temperatures, but they find the wetness of winter unpleasant.   The ducks seem like stay outdoors in all conditions except blizzard conditions which they ride out in their duck house.   The guinea fowl, our flying dinosaurs, seem capable of handling any “fowl” weather.

The Great Pyrenees dig, role, and relish the snow.   They are in 6 feet of heaven.

I use my avalanche shovel to keep the bee hives clear of snow.  I’ve felt like a Sisyphus shoveling snow away from the hives every night, then waking to find them covered again.

As the next storm approaches, the sand barrels are filled will 100 pounds of dry, general purpose sand. Five hundred pounds of calcium chloride/magnesium chloride are stacked in the barn, ready for safe ice melting around vegetation.   The diesel and gas tanks/storage are full.   The shovels are placed near each key doorway.   I even removed a pasture gate so that the new “snow parking lot” will not be blocked by a snow covered barrier.

The next few days will see high temperatures below 10F and lows below -10F.   This week I replaced the heater base for our water fonts in the coop - they failed from overuse.

As my wife says “The Winter of 2015 - I’m ready to Let It Go!”

The February HIT Standards/HIT Policy Joint Meeting

The February HIT Standards Committee was a joint meeting with the HIT Policy Committee to align the policy and technology work ahead in 2015.

Erica Galvez began the discussion by reviewing the recently published Interoperability Roadmap.  She first highlighted supportive business, clinical, cultural and regulatory environments:

*On January 26, HHS and CMS announced that they are aiming to have 30 percent of Medicare fee-for-service payments tied to quality or value through alternative payment models by the end of 2016,and 50 percent of payments by the end of 2018.
*Requirements for participants in these new models can reinforce interoperability.
*Near term actions for the Federal government include linking policy and funding activities beyond Meaningful Use to adoption and use of certified health IT and electronic information sharing according to national standards.
*Near term actions for state government include a “call to action” to use available levers and Medicaid purchasing power to expand upon existing efforts to support interoperability and explore new options.
*Near term actions for non-government payers/purchasers include a  “call to action” to explore financial incentives and other ways to emphasize the interoperable exchange of health information among provider networks.

Erica continued with a discussion of governance, emphasizing the need for a framework than a new organization with “top down” authority.  

She then continued with an overview of privacy and security protections for health information including the need to address the variation in state rules which make it difficult to build software systems that accurately capture, maintain, and persist consent data.  ONC’s role is to help facilitate the alignment of policy among all stakeholders.

We then discussed the core technical standards/functions and certification/testing to support adoption and optimization of health IT products and services.    Near term actions include ONC’s effort to publish annual list of best available technical standards for core interoperability functions.   The private and public sectors must:

• Define a common clinical data set to achieve semantic
interoperability
• Constrain implementation of the C-CDA
• Advance standards for data provenance at the document and data element
level
• Advance standard, open RESTful APIs to support simple, scalable
interoperability

Erica concluded with a discussion of the next steps.   Workgroups were assigned sections of the roadmap to review to make the best use of resources and avoid overlap.

Steve Posnack continued with an overview of the recently published Standards Advisory document.  The goals of the Advisory are to be specific about the best standards available for each purpose.  It’s a non-regulatory approach with an interactive, predictable process.  Hopefully it will be a widely vetted resource that  will enable a “look first” philosophy for government programs, procurements, testing or certification programs, and standards development.

Steve then provided a Certification Program update including plans for quality improvement, greater transparency, increased collaboration, and improved customer service.

Finally, Dawn Heisey-Grove and Elisabeth Myers provided an update on Meaningful Use attestations.

A great meeting with many next steps.    It’s clear that interoperability will significantly increase when the right standards, supported by constrained implementation guides, are paired with consent/security policies widely accepted by all stakeholders.

Unity Farm Journal - First week of February 2015

We’ve had nearly 4 feet of snow this week, sub zero temperatures and high winds.    The barnyard looks like the grand canyon with piles of snow 7 feet high.    The Terex PT-30 Compact Track Loader can lift 1000 pounds of snow at a time and we’ve cleared 2 acres of snow for all the creatures that live on the farm.  

My years as an alpinist (pictured below) have prepared me well for shoveling manure in the dark at sub zero temperatures.   As a farmer, I cannot sleep in, wear my bunny slippers and sip tea by the fire.   Every morning, over 100 lives depend on me to feed them, provider water, and clean their living spaces.   At the moment, every creature is warm, dry, hydrated, well feed, and loved.

The driveway to Unity farm is a quarter mile long.   It’s just the same as shoveling your driveway, with a different scale.   When 4 feet of snow fall, the issue is not finding someone to plow.   The issue is finding somewhere to store all that snow.

The hoop house vegetables continue to grow under their row covers even in the subzero temps.   Spinach, Romaine, and Winter Density Lettuce are particularly successful.   I pick them every day for the humans and the creatures which all enjoy their greens in the depth of winter.

The bird feeders are filled with high calorie seeds and suet.   Dozens of species visit the farm every day for food, water, and warmth.    I find Carolina wrens, sparrows, and blue birds sleeping in the barn every morning.

The work of keeping a farm productive in the winter requires attention to detail - shoveling around the generator, keeping the bee hives well ventilated by clearing snow, using additives in gasoline and diesel to keep the machinery running, splitting wood every day, and heating all forms of water to keep the animals hydrated.

This winter is proving to be more difficult than the last, but thus far, everyone is healthy and happy.   My productivity given a 4 bar LTE connection to mobile devices, a high speed fiber network on the farm, and multiple teleconferencing modalities has worked seamlessly, so that every part of my work life has continued through the storms without missing a beat.

The next week will be marked by more snow and continuing subzero temperatures.   I look forward to the end of snow management and the beginning of early spring indoor seed germination in the weeks ahead.

The athenahealth/BIDMC Collaboration

BIDMC has self-developed its core clinical information systems for many years.  We certified all our applications for the 2011 and 2014 ONC criteria, attesting to Meaningful Use Stage 1 and 2 in every appropriate year.   BIDMC has hundreds of person-years invested in our web-based, cloud-hosted in-patient and out-patient applications.  The culture of BIDMC has always been to challenge to the status quo, to be willing to be a first mover, and to focus on value—establishing the highest quality at the lowest cost.

But the days of self-built systems cannot last forever.  While we want to continue to innovate, we know that commercial vendors will be able to leverage their knowledge and capabilities to build future platforms at larger scale.

We know those platforms will need to support evolving capabilities. I have long believed that the key to the future of healthcare involves maintaining wellness across the continuum of care, not optimizing the treatment of episodic sickness in silo-ed organizations.   Academic medical centers are important for research and education, but the majority of care can be delivered safely in community hospitals and practices near the home, at lower cost.  The HIT software of the future needs to leverage the experience of internet centric companies, offering cloud-hosted services with a zero client footprint, easily deployable in all sites of care.  There should be no special browser, desktop, or infrastructure requirements.   The services should be delivered via a subscription model that can be easily turned on and off as needed.   Products should include practice management, billing, a patient/clinician inpatient/outpatient shared medical record, care management, population health, and an app store of third party developed mobile products.

During my life in New England, I’ve had the opportunity to work with several professors specializing in negotiation theory.   I’ve learned about the importance of aligned interests.  

athenahealth is a cloud-hosted service provider with billing, ambulatory clinical, and population health products.    It has a culture of rapid cycle improvement and disruptive innovation.

For all of these reasons, BIDMC and athenahealth announced a new and unique collaboration. The collaboration between the two organizations provides athenahealth the chance to take BIDMC’s experience to a much larger audience, hopefully making a difference to providers, patients, and payers across the country.   athenahealth will also accelerate its ability to develop expanded functionality more rapidly than doing it alone.

I have always served as Geneva, a neutral convener.   I hope that the industry understands that I will not receive any compensation or personal benefit from the collaboration.   I do not and cannot own any athenahealth stock.  BIDMC will not write code for athenahealth’s new products nor receive royalties.   BIDMC’s community hospitals will continue to implement the cloud hosted, web-enabled Meditech version 6.1x for inpatient support.  Many BIDMC community practices use eClinicalWorks.

Over the next 5 years at BIDMC, we will select the best products and best services that meet the needs of our highly diverse network.   athenahealth products will be piloted in outpatient and inpatient locations.   We certainly hope that athenahealth produces excellent products but at BIDMC, we are a meritocracy and the best services at the lowest cost will win.

Just as Mayo chose Epic to reduce the number of different IT systems, BIDMC will pursue a parsimony solution - the fewest moving parts possible.  That might be one vendor, but hopefully it will not be more than two.

I look forward to seeing what happens  as webOMR moves from a 25 person development team to a 1500 person development team.

The future belongs to social, mobile, analytics, and cloud.   The transfer of our self-developed software to athenahealth will give the industry a unique opportunity to explore the cutting edge of the possible.