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.

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.

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.

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.

What is the Optimal Future Role for ONC?

As Meaningful Use winds down and incentive dollars are fully spent, what is the optimal role for ONC going forward?

Some pundits have suggested that ONC step aside and return all aspects of HIT policy and technology to the private sector.   Others have suggested top down command and control of HIT including centralized governance to ensure interoperability.

Harmony is when all parties feel equally good about the path forward.  Compromise is when everyone leaves the table equally unhappy.   Here’s my view about the future of ONC that includes points from both sides.

The Argonaut initiative is a good exemplar of the private sector working to enhance interoperability in response to the market demands of accountable care organizations, which depend on data to succeed in a risk contracting world.    There is clearly a role for the private sector to lead innovation and standards adoption, and this role will continue to grow as demand for richer interoperability increases and technology matures.   However, even the best innovations require a regulatory and ecosystem context to enable the marketplace to blossom.   The health care sector is the most fragmented industry in our complicated economy, both on the demand side (patients, insurers, employers) and on the supply side (physician practices and hospitals).  ONC can be a focal point for the discussion of regulatory barriers to data liquidity, novel workflows, and alignment of incentives.

In Massachusetts, opioid abuse is a critical public health problem.   We believe that collecting all opioid prescriptions at a state government level and sharing that data with licensed caregivers is appropriate.   Yet, right across the border in New Hampshire, it’s illegal to share such data with government entities.  Similar prohibitions exist on sharing immunization data to prevent measles outbreaks or syndromic survellience data to detect Ebola.   Extrapolate this problem out to the various combinations of 56 states and territories and it's an interoperability nightmare for patients, providers, and vendors.  ONC can provide national frameworks that enable regional variation but can suggest guardrails so that a federated national network of interoperability and functionality is not impeded.

Canada has 35 million people.   Sweden has 10 million.   Healthcare IT policymaking that takes into account stakeholder opinions in these countries is easier than resolving the difference of 320 million US residents.   Someone needs to be a convener to give voice to the myriad stakeholder priorities of a country that glorifies individual freedom.   ONC can be such a convener.

The US government is a large player in the health care market, even aside from any oversight role it might play.  Medicare and Medicaid are the largest health insurers in the country.  The US government has over 20 million employees whose health benefits it covers.  The DoD, VA, and Indian Health Services are large providers of care.  The number of federal agencies and the many and varied ways that they affect health care delivery and health information technology is hard to quantify.   There is no single front door in the federal government for HIT related strategic planning across agencies.    ONC can serve as government agency harmonizer.

Although Accountable Care Organizations now have economic incentives to accelerate interoperability, they do not have specific incentives to focus on healthcare IT usability and the safety of IT tools.   We are now at a point where everything that happens in a hospital is somehow tied to information technology.  ONC can provide funding to study issues that lack a specific private sector market force, just as NHTSA and NTSB do with auto and airline safety.

Finally, although there are many federal and state laws that protect privacy and security, it is challenging to know how to measure the security of an EHR.   By working with other federal agencies to identify best practices, ONC can foster data integrity and promote respect for patient privacy preferences.

Thus, although the private sector can lead innovation and accelerate standards development, the combination of government, industry and academia is needed to optimize our journey.     I recently spoke with a cabinet secretary in the Massachusetts government and the person told me “the Baker Administration does not believe in less regulation or more regulation, it believes in right regulation.”    The same can be said of the balance between ONC and the private sector.   The list of tasks above seems like the “right regulation” to me.

Unity Farm Journal - 4th week of February 2015

With Spring arriving in 23 days, the farm is beginning the transition from surviving the bitter cold to nesting and reproduction - the Birds and the Bees.

First the Birds.    I sent my daughter the picture below and asked her if she could guess what happened?

Over the weekend,  I went into the coop to fill the feeders and found a dead guinea surrounded by a pile of feathers.   

 I looked up and a large red tail hawk was standing on the roost above my head.

I removed all the guineas/chickens and closed the coop door.    Not knowing how the bird would respond to my interventions I asked Kathy to supervise me in case I was attacked.

Wearing my kevlar work gloves I gently picked up the bird by its talons and placed it on my arm so I could walk it out of the coop.     The bird and I had a conversation for several minutes.   I explained that I respected its position at the top of the local food chain,  but that Unity Farm could not be a weekly smorgasbord during the lean times of winter.    As you can see in the picture, our discussion was intense - direct eye contact and uninterrupted focus.    The bird and I walked to the orchard and I encouraged it to fly by gently moving my arm up and down, exercising the raptor’s wings.    The bird then flew off, circled the barnyard once, and roosted in a tall old maple snag.   

Although I have no desire to take up falconry (it’s not very vegan), I did read about the history, training techniques, and bird personalities involved in the sport.   Red tail hawks are known for the equanimity - a very even temperament.    They never develop affection for their handlers, but they do develop trust.   Given the chickens,  ducks and guineas at Unity Farm, we do not want the hawk to visit often.   

Next, the Bees.

On Sunday, the temperature rose above freezing for the first time in a month.   The bees cannot fly below 40 degrees, and in general, we do not open the hives below 50 degrees.  Bees do not excrete in the hive, so they have had to “hold it” for the past 30 freezing days.    As soon as the temperature hit 45F, our 100,000 bees began their cleansing flights.   

We have not been able to open the hives since January, so we had now idea how the hives were overwintering through -10F temperatures and weekly snowstorms.   Every Sunday I have shoveled out the hives, but the snow between the barn and the hives requires walking 1/4 mile in 7 foot deep snow - challenging even with snowshoes.     A stethoscope can be used to listen for “buzzing”, a crude measure of hive survival.   My initial examination suggested that two of the twelve hives had not survived the unusually brutal winter.  Clearly we needed to do an emergency inspection and decided that the 45F temperatures would be sufficient for a very quick look.

I carved a path to the hives and Kathy brought 18 sheets of fondant (sugar icing).  One by one we opened each hive and added food.    As we feared, two hives did not survive, but we found no clear evidence of nosema, american foulbrood, or heavy varroa mite loads.   Once the weather warms we’ll look at all the hives, frame by frame.

One possibility is that the snow drifts were so high, the warmth of the sun from the south was blocked by the shadows of the enormous piles.    Next week, the snowblower attachment for the front loader arrives and I’ll be carving paths, reducing drifts, and making management of the entire farm infinitely easier.    I’ve worn out my alpine climbing gear by simply traversing the farm this winter.   Using a commercial snowblower is  a much better strategy than an ice ax, snow shoes, and total body vortex. 

As March begins, I’m hopeful the snow will stop and the sun will shine, warming the hoop house to the point we can begin planting.    Maybe next weekend I can finally get the peas in the ground.    The lettuces, spinach, chard, bok choi, and mache have overwintered well - we’ll have our first harvest in early March.

Making Time for Innovation

CIOs are at a challenging crossroads in their careers.   Regulatory burdens, security threats, and changing reimbursement models have led to a demand for change that seems overwhelming.   As workflow pressures increase, it’s easy to declare IT the rate limiting step.

Given that many CIOs are ready to raise the white flag of defeat in desperation, finding time for innovation amidst the swirl of must do projects can be a challenge.

My hope, and something I strive to do, is to take the long view, asking what innovations we’ll need in the next few years, which will enhance productivity, and possibly serve as generalizable tools, reducing the number of requests for niche systems.   As I think about 2016, here are a  few of the kinds of innovations I think we’ll want for healthcare organizations:

1.   In our home  lives, we use cloud hosted storage accessible  on our personal devices.     How can we give folks the same easy access to their files (in lieu of the SSLVPN web-based access) while still protecting patient privacy?

2.  In our home lives, we use social networking - Facebook, LinkedIn, and Google+ to provide collaboration spaces for sharing ideas, messages, and files among groups.   How do we offer these kind of applications to support our work lives?  Is Slack a good fit for healthcare organizations?

3.  In our home lives, we use texting for communication among teams.   How do we deploy secure, enterprise grade texting that is fault tolerant, supports delegation (if you are unreachable),  role-based messaging (the current administrator on call, whoever that is), and audibility.   Per Harvard rules, I must disclose that I serve on the Board of Directors for Imprivata which produces such a product.   I will recuse myself from any decision making processes about secure texting procurement.

4.  As I’ve blogged about previously, patient generated healthcare data will become increasingly important and we need to be able to incorporate objective data (home devices) from smartphone middleware like HealthKit and subjective data (electronic patient reported outcomes).

5.  Interoperability use cases will increasingly require closed loop transactions with tighter coupling among organizations.   The FHIR work accelerated by the Argonauts group is the best path forward to achieve this goal.

As usual, sometimes we buy innovation and sometimes we build innovation.   If practical, we should procure these services from cloud-based software as a service providers.

We need to work closely with our compliance and legal colleagues to balance risk and benefit, accepting that with all change and innovation there is a risk of the unknown.    We can mitigate risk in the face of ambiguity.

Often organizations focus on the short term - the tyranny of the urgent.   Carving out time for innovation with a long term view is necessary to create true breakthroughs.   A dozen short term sprints will not add up to the marathon of transformation that is only accomplished via a steady pace over time.