Unity Farm Journal - Second Week of May 2016

It’s Spring so it’s time for new farm babies.   Welcome Athena and Apollo, two baby geese born this week.    They have the benefit of 3 mothers and 1 father watching over them.   The adults took them to the pond and taught them how to swim within a few hours after hatching.   We’re keeping the goose pen closed during the day when we’re not around because of all the hawk activity.   A week old goose is an easy target.

Temperatures are edging up to the mid 70’s so the pigs are getting hot.   Yesterday, we moved them to their summer paddock with its shade and cool mud.   The pigs are very smart and aren’t sure why they are on “vacation” from their usual home, but I’m sure they will adapt soon.

Now that the weather is warmer we’ve been able to drain, clean and maintain all the ponds around the barnyard.   A winter of accumulated goose poop can create quite a cleaning challenge, including a rotten egg or two in the muck.    All our water features are running perfectly now and we’re ready to be the local watering hole for dozens of species over the summer.

This week we sold lettuce, mushrooms, and spinach to Tilly and Salvy’s, our local farmstand.   We’re learning an immense amount about consumer behavior  - what we should grow and how we should package it for maximum sellability.   Although we’re nearly done with our Umass organic farming courework, it’s the day to day activity of selling at retail that really teaches you farming.  

Our organic certification application was accepted as complete this week, so now we await our unscheduled inspection (a kind of Joint Commission visit for organic farms) and then hopefully we’ll join the ranks of USDA certified organic producers.  

In today’s complex world, certifications and compliance require perseverance.   We’re one of 7 bonded cideries and one of 72 bonded wineries in the state of Massachusetts. Add the organic certification to that and Unity Farm will be unique in its accrediitions.

Kathy is very busy with the bees now that we’re approaching honey making season.   We’ll be running about 25 hives this year in 4 locations.   I suspect this will be the year that we’ll upgrade our hand cranked honey extractor to something more automated.

This weekend we’ll be doing the final preparations for my daughter’s wedding next weekend at the farm - trimming, planning, and cleaning.   By next weekend, we’ll be ready for the cover of Farm Beautiful magazine!

Rethinking MACRA, a follow up

In my blog posts, I speak from the heart without a specific political or economic motivation.   Although I’ve not written about highly controversial subjects such as religion, gun control, or reproductive policy, some of the topics in my posts can be polarizing.   Such as was the case with MACRA.   Some agreed with my initial analysis that clinicians will have a hard time translating complex MACRA payment processes into altered clinical behavior.   Others felt I was overharsh, negative and inappropriate.    It’s never my intent to criticize people, instead I want encourage dialog about ideas.    In that spirit, here’s my opinion on how we should evolve from fee for service to pay for value/outcomes.

1.  Humans can never really focus on more than 3 things at a time.  Although we sometimes believe multi-tasking is efficient, in reality we do work faster with less quality.    Instead of 6 or 8 dimensions of Meaningful Use performance combined with a large number of quality indicators, why not delegate each medical specialty the task of choosing 3 highly desirable outcomes to focus on each year, then reward those outcomes?  For example, I have glaucoma.   Asking my opthalmologist to record my smoking status or engage in secure messaging with me is probably less important than ensuring my intraocular pressures are measured, appropriate medications are given, and my visual field does not significantly worsen.    The cost to society of my blindness would be significant.    Keeping my sight intact represents value.   Care Management software could ensure I’m scheduled for pressure check appointments, given medications, and have my visual field checked once per year.   Some percentage of reimbursement could be withheld until those outcomes are achieved. How  software does that is not important and innovative workflow would be left to the marketplace where clinicians will choose applications based on usability, cost, and time savings instead of regulatory oversight.

2.  Care coordination is important and there is a role for government to drive consensus around standards selection.   Certification could be limited to an application’s ability to perform a few key interoperability functions such as

a.  Look up a recipient address from a national provider directory and send a clinical summary of care (transition, referral request, consult note) to that address securely

b.  Query a record locator service/master patient index and retrieve a list of electronic addresses where patient data is stored, then be able to retrieve a small common data set from those locations (problems, meds, allergies, labs, notes)

c.  Be able to send a clinical summary of care to a patient provided electronic address.

d.  Be able to send a small number of data elements to a relevant registry

e.  Be able to participate in a prescription drug monitoring program

Each of these functions would use a single standards implementation guide without significant optionality,  tested in the marketplace and deemed mature enough for use.  How these transactions are implemented in workflow would be up to each vendor.    Certification would test nothing more than successful transactions against a publicly available test bed.

3.  All other Meaningful Use criteria and quality measures would be eliminated so that clinicians can focus on just the three goals per year relevant to their specialty while  working in an environment that thrives on the simple information exchanges listed above.

We need to avoid unnecessary burden for clinicians, hospitals and software developers.   Think about all the effort (and dollars) spent during the Meaningful Use Stage 1 and 2 processes to report quality measurements, which were never used for anything.   Think about all the certification done that was not related to health policy goals or outcomes.  Think of all the data entry required which resulted in clinicians  spending time practicing below the top of their licenses.  

Focusing on 3 outcomes per specialty which are easily measurable, while radically focusing certfication on a few key interoperability transactions is likely to be acceptable to provider and developer stakeholders.   The big question - would it satisfy CMS goals for MACRA based on Congressional mandates?  I hope to have that dialog in several forums over the next few weeks.

A Deep Dive on the MACRA NPRM

As promised last week, I’ve read and taken detailed notes on the entire 962 page MACRA NPRM so that you will not have to.

Although this post is long, it is better than the 20 hours of reading I had to do!

Here is everything you need to know from an IT perspective about the MACRA NPRM.

1.  What is the MACRA NPRM trying to achieve with regard to healthcare IT?

The MACRA NPRM proposes to consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals (EPs), creating a single set of reporting requirements.  The rule would sunset payment adjustments under the current PQRS, VM, and the Medicare EHR Incentive Program for eligible professionals.

2.  Who is affected?

In the MACRA NPRM, the word Eligible Professional is replaced with the term Eligible Clinician, expanding the population of individuals covered by Merit-based Incentive Payment Programs (MIPS).  MIPS eligible clinicians will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians.   Hospitals are not affected by this rule and  hospital-based MIPS eligible clinicians are not required to participate in the information technology portions of MACRA, since they may not have direct control over the software implemented by the hospital.

3.  When does the rule take effect?

The rule proposes that the first performance period would start in 2017 for payments adjusted in 2019.   It’s not exactly a stimulus program - some clinicians will see reduced payments for non-performance and some will see enhanced payments for exemplary performance - a zero sum redistribution of payments.

4.  Does Meaningful Use and electronic clinical quality measure reporting go away?

MACRA’s enactment altered the EHR Incentive Programs such that the existing Medicare payment adjustment for a eligible professionals ends after calendar year 2018.  Generally,  MACRA did not change hospital participation in the Medicare EHR Incentive Program or participation for professionals in the Medicaid EHR Incentive Program.

Meaningful use of certified EHR technology is renamed to  “advancing care information” and the criteria are streamlined - removing the CPOE and Clinical Decision Support requirements.   In 2017, clinicians may still use 2014 edition certified technology and report on eight Stage 2 measures.   By 2018, clinicians need to use 2015 edition certified technology and report on six Stage 3 measures, described below.

Quality measures will be selected annually through a call for quality measures process.

5.  What is the role of ONC and Certification?

On March 2, 2016, ONC published the ONC Health IT Certification Program: Enhanced Oversight and Accountability proposed rule, which would expand ONC’s role to strengthen oversight, requiring that clinicians give access to their EHR for “field inspection” of functionality by ONC.

The MACRA NPRM proposes that clinicians must attest they have cooperated with ONC surveillance and oversight activities.  Further, they must attest they have not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.

6.   What are the MACRA advancing care information objectives and measures that have replaced Meaningful Use?

The six criteria which are required as of calendar year 2018 are

1. Protect Patient Health Information - Security Risk Analysis
2. Electronic Prescribing
3. Patient Electronic Access - Patient Access, Patient-specific education
4. Coordination of Care through Patient Engagement - View/Download/Transmit, Secure Messaging, Patient Generated Health Data
5. Health Information Exchange - Patient Care Record Exchange, Request/Accept Patient Care Record, Clinical Information Reconciliation
6. Public Health and Clinical Data Registry Reporting - Immunization Registry Reporting

Here are examples of the actual measurements:

Secure Messaging Measure: For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative).

View, Download, Transmit (VDT) Measure: During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. An MIPS eligible clinician may meet the measure by either—(1) view, download or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician’s certified EHR technology; or (3) a combination of (1) and (2).

7.  So what must a clinician do and when?

For the period January 1, 2017 to December 31, 2017 (yes, it’s a full year, not 90 days), clinicians must
a.  Use a 2014 or 2015 Edition Certified EHR
b.  Report on either eight stage 2 or six stage 3 advancing care information objectives and measures:
c.  Attest to their cooperation in good faith with the surveillance and ONC direct review of their EHR
d.  Attest to their support for health information exchange and the prevention of information blocking.
e.  Continue to practice medicine

Sorry, e. was an attempt at humor.    Listening to each patient’s story, being empathic, and healing are optional.     After spending 20 hours reading the MACRA NPRM, I had one overwhelming thought.    Sometimes when you remodel a house, there is a point when addtional improvements are impossible and you need to start again with a new structure.    The 962 pages of MACRA are so overwhelmingly complex, that no mere human will be able to understand them.    Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes.    This may sound cynical, but there are probably only two rational choices for clinicians going forward - become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.

The folks at CMS are very smart and  well meaning, but it’s hard for me to imagine implementing the NPRM as written in the timeframes suggested.   I will watch closely for comments from organizations such as the AMA, AHA, and clinician practices.    I’m guessing that many will see the ONC Surveillance provisions as overly intrusive and the "advancing care information" requirements as creating more burden without enhancing workflow.    Maybe the upcoming Presidential transition (whoever is elected) will give us time to pause and reflect on what we’ve done to ourselves.    As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.

Unity Farm Journal - First Week of May 2016

I’ll be 54 this month and this week we delivered 54 heads of organic lettuce to Tilly and Salvy’s, the local farm stand selling Unity Farm products.  Who would have thought that my “portrait” would look like this at 54

Here’s what the fresh organic vegetabes growing at Unity Farm look like this week.

I dropped by Tilly and Salvy’s on Sunday afternoon and spoke with a customer buying our produce.    I introduced myself as the farmer and she thanked me for growing such wonderful fresh vegetables.

It’s been a wild week - I had to be in Chicago, Las Vegas and Houston from Monday-Thursday.     That left Kathy at the farm in charge of the maturing vegetables, animals at the peak of mating season (chickens, ducks, geese, and guineas are all broody), and our annual alpaca shearing.  When I agree to travel a year ahead of time, this always happens.   As a farmer, living things always come first, so travel becomes increasingly problematic (or stressful for your spouse!)

Shearing went well although it has been raining, so keeping the alpaca dry was an adventure.     Kathy called in a few friends to help.   No animals or humans were harmed in the process.

Also in my absence, a tree company removed  the “widowmakers” - trees that partially fell or branches that partially broke during the winter.    Now that the ground is drying out and mud season is over, the trucks can navigate the forest roads.    Although I do all the forest management myself, I draw the line at activities that could result in a 10 ton tree or 1 ton branch falling on me.

I’m flying back from Houston tonight after giving a commencement address at the University of Texas.

I’ve heard that the pigs miss our nightly tuck in rituals and the dogs are desparate to explore the territory that the coyotes have been visiting outside the paddocks.    It’s clear that there is a litter in the den since the female coyote is visiting the farm every day looking for food.  Thus far, her hunting activities have been unsuccessful.

I’ll spend the weekend doing all the farm work that I should have done on early mornings and evenings during the week.  The next few weeks will be a bit chaotic with my daughter’s upcoming farm wedding and move.    All is well.

Unity Farm Journal - Fifth Week of April 2016

Unpredictable New England weather continues - we’ve had temps in the 70’s and temps below freezing.   Hard frosts are tough on new leaves and buds, so we’re assuming the fruit tree crops will be diminished this year.    We’ll hold off on hoop house planting of our tomatoes, peppers, and eggplants until the first week of May.  Although we may have cold weather in May, the soil temperatures of the hoop house are likely to be sufficient to support cold sensitive plants.

We’re continuing our Sunday morning lettuce harvest ritual.   This year, we’ll be able to sell about 500 heads of Boston, Bibb, and Romaine from our hoop house.

This week we submitted our Organic Certification application that includes all the data we need to seek approval for the “USDA Organic” symbol to appear on our mushrooms, fruits, and vegetables.   In the upcoming weeks, we’ll have an unannounced inspection of our orchard, hoop house, and mushroom growing yard.   Organic growing requires use of materials that appear on the  Organic Materials Review Institute lists as well as use of organic seeds/seedlings.    We believe we’ve done everything right to achieve certification, but the inspector will let us know soon.

The alpacas and llama get sheared on May 4, and aftewards they’ll be itchy.   Think of giving your wool sweater a haircut.   A nearby sweeping company donated a 6 foot sweeping wheel and we mounted it as a scratching post in the female paddock.   Here’s the new alpaca back scratcher ready for action.

It’s Spring and our outdoor activities mean more exercise and better fitness.    At Unity Farm, we do a variety of strength building exercises.

Here’s an example of farm Yoga - we call it “The Downfacing Pig”

Some pursue Pilates but on the farm, we prefer Piglates  - stretching while rubbing two pig bellies simultaneously.   Very challenging.

This weekend, we’ll bottle 30 gallons of Honey Lager and plant all our tomatoes, peppers, and eggplant in the beds we’ll empty of winter letttuce.    Next week I have to be in Chicago, Las Vegas, and Houston for various speaking engagements, so Kathy will be running the farm alone.    I’ll be back on Friday to help finalize all the final preparations leading up to my daughter’s wedding on the farm at the end of May.

The MACRA Notice of Proposed Rulemaking

This afternoon, the MACRA Notice of Proposed Rulemaking was released.  I'll publish a comprehensive analysis of the 900+ pages next week, but in the meantime, a few thoughts.

The major ideas are:

*The ONC 2015 Certification Rule applies to all technology used to satisfy MACRA requirements

*Meaningful Use is being replaced by a more flexible construct that is tailorable to specific workflows and specialty practices

*Quality Measures can be selected by each practice to be relevant and aligned with their goals.

This NPRM applies to physician practices only, not hospitals, so we do not yet have clarity on the future of Meaningful Use for hospitals.

Many of the concepts are good - reducing documentation burden, enabling flexbility, focusing on outcomes/quality, engaging patients in novel ways, and emphasizing connectivity/interoperability.

However, the use of  the ONC 2015 Certification Rule is probably not a good idea.      The 2015 Rule is a kitchen sink of standards, many of which are not ready for production deployment.   The Rule is an example of regulatory overambition - instead of narrowing the scope to specific goals or workflows, it includes a cornucopia of use cases unrelated to Meaningful Use.    I highly recommend that we use the Standards Advisory concept to provide a constrained list of standards  but then let vendors innovate as needed to support the workflows desired by patients, clinicians, and hospitals.   Using the 2015 Certification Rule as written will have 3 bad consequences:

*The burden of certification will consume  developer resources that could be used for innovation
*The standards listed in the certification rule have varying degrees of maturity and we'll be setting in concrete some technologies that should not be used
*The certification rule did not envision the kinds of products or services the private sector would develop 2016-2018

I applaud a focus on outcomes and quality.  Meaningful Use has run its course and achieved its goals.   It needs to be replaced.     Along with replacing Meaningful Use, let's rethink the certification concept too.     More to come next week!

Being a Cancer Treatment Partner

Recently my wife was asked to advise one of our friends about the process of cancer treatment.    As I wrote in my 2011 post about our family's experience with cancer, the treatment involves everyone close to the patient.   Here are Kathy's notes for families of cancer patients, which I post in the hope that they will help others.

"I promised  to pencil out tips for how you can best serve as a cancer treatment partner.

Here is a great resource to read on the general way to help.

At the treatment planning visit, you should take notes so the patient can remember things later more clearly. Also, if you have a list of questions the patient specifically wants answered, you can remind her of them if she forgets to ask her doctor.

You will want the details of the final staging results, but  have found that it is not useful to focus too hard on longevity curves and results because your individual case will follow its own course. You already take the diagnosis seriously.

Confirm the details of the radiation plan.
Ask what the side effects are.   Long term risks.
Confirm the details of the chemotherapy plan.
Do you need a port?
Ask what the side effects are of your chemotherapy. Long term risks.
Do you need to look at clinical trials?
Ask about the specific drugs used for the supportive/palliative part. Palliative is the word to define the pain relief team and elements that relieve any discomfort you have from the tumor or the therapies.
Is there anything you should not take while on their treatment (like ibuprofen or any other prescriptions, or food/vitamin)
One of my own chemo therapies involved intravenous Benadryl so I could not drive myself home during that one. So ask if there are any guidelines for your specific treatment.
Ask about any risks of neuropathy (numbness in hands and feet) from chemotherapy, and what dialog or change in treatment plan they expect if you should experience neuropathy. Ask about any plan or need to boost white blood counts with therapies such as Neulasta. Connected to that is any discussion of increased risk of catching viruses or infections due to a suppressed immune system.
If you have questions about surgery and why they do not recommend it - simply ask why they find it to be not recommended in your specific case.
Ask about alternative and supportive therapies (nutrition/massage/etc)

After this initial treatment, what tests will be performed to evaluate the degree of remission?
What are the current tumor and post treatment impacts on function?
Are there ongoing post treatment medications you will have to take. Six month, one year followup plan, and beyond.

 Only use a second opinion if the treatment plan does not align with your own comfort zone or desires."