Building Unity Farm - Adopting Alpaca

Memorial Day weekend was a busy time at Unity Farm - spending time with our newly adopted alpaca, doing woodland/forestry management, and inoculating mushroom logs.

How did we adopt new alpaca?

In an unusual chain of events,  a leading alpaca breeder in Maine was the former editor of a healthcare IT magazine and knows me well.   When she heard about a family in Massachusetts trying to place their three alpaca, she recommended Kathy and me as caring adoptive parents.

We gently loaded the alpaca into a transport vehicle and drove them 20 miles from their current home to their new home at Unity Farm.

Since we're introducing new animals to an existing herd, we decided to quarantine them for 4 weeks in our pasture, away from the other alpaca.    

We drove the vehicle into our pasture, closed the gate, and let the alpaca step out on their own.   The picture above shows our newly adopted alpaca - Juniper (dark brown), an 8 year old female; Mint (white), her 2 year old daughter;  and Tahoe (light brown), an 8 year old gelded male.

They have their own loafing shed, hay supply, minerals, grain bowls, and half an acre of orchard grass to munch.  

Our traveling large animal vet will visit them on June 5.  We'll update all their inoculations, do fecal samples for parasites, and begin injections of ivermectin as a preventive treatment for meningeal worm.

Since we had a 3 day weekend, we also aggressively worked on woodland management.   Now that the orchard has opened up the lower 5 acres of the property, I began hauling fallen trees to the woodcutting area and wood chip grinding area.

Saturday was devoted to clearing an old hickory tree that blew down in hurricane Sandy.  Hickory is the finest firewood available - easy to split, yields high heat, and burns cleanly.     I added half a cord of split hickory to our 5 cords of firewood storage.

Sunday was devoted to ash.  Over the past few years a virus killed many old ash trees and the emerald ash borer caused dieback of ash trees in New England.   Some of those trees have fallen and some are still standing, likely to fall in the next big storm.  I began the process of clearing ash and moving it to the woodcutting area for splitting.  Ash does not require aging and can be burned immediately.   We lit a roaring fire of freshly cut ash wood on Sunday night since the temperatures on the farm dropped into the 30's.

Monday was devoted to poplar.   Many of the poplars on the farm are 65 feet tall and are approaching an age when they are likely to fall in a storm.   Poplar is poor firewood and we generally chip it for use on our trails.    On Monday, I was spreading mulch on the Orchard trail, a winding path between the orchard and our stream.   I stopped for a moment to check email and received an important budget to review.   I walked to the house to view the spreadsheet on a larger screen.   While sitting at my computer, I heard a loud explosion from the lower portion of the property.   Everyone on the farm ran to discover the source of the disturbance.  What we saw made us turn pale.   A 5 ton poplar had fallen on the exact spot I was standing while spreading mulch.   It crushed a portion of the orchard fence and ripped down the gate, 50 feet away.    Can an email save your life?  On Memorial Day, an email saved mine.    It's hard to imagine an obituary that reads "John was standing in the forest when a 10,000 pound poplar spontaneously fell on top of him."    

My wife gave me a large chainsaw for our 28th anniversary last year (the traditional gift), so we had the tools necessary to carefully cut up the 18 inch diameter trunk into 200 pound chunks which we carried to our grinding area.   We temporarily stabilized the fence (two posts were broken and one crossbeam was smashed.    At the moment, the orchard is still deer proof while we await permanent repair.

Finally,  Kathy and I finished our first 110 Shitake mushroom logs - 5000 holes, 30 pounds of mushroom spawn, and 10 pounds of cheese wax to seal the holes.     We can process about 300 pounds of oak per hour, which we did in the late afternoon on Saturday, Sunday, and Monday.     Now that the first 11 oak stacks are completed, each with a different sub-species of Shitake, we'll work on expanding the size of the stacks so that by the end  of June we'll have completed 220 logs - a total of 15,000 pounds of wood.

Luckily, next weekend we'll be moving our daughter into her own apartment at Tufts University.   After our farm workouts, hauling furniture should be easy!

Clinical IT Governance Update

Yesterday I led the Clinical IT Governance meeting at BIDMC and I thought it would be interesting for my readers to get an inside look of the kind of topics we're discussing and how we're implementing our most challenging projects.

1.  Joint Commission debrief
Last week the Joint Commission visited BIDMC and the experience was very positive.  When there are process variations and potential shortcomings identified by the Joint Commission, IT solutions are often suggested.   In this particular visit, there were a few small software changes made during the visit to better support National Patient Safety goals such  as ensuring all care team members know the preferred oral and written language preferences of each patient.   We made modifications to ensure all our sites of care - ED, inpatient, outpatient, OR, and ICU gather this information consistently and display it routinely.   That was the only issue involving IT in this Joint Commission visit.

One of the great challenges of IT governance is maintaining focus on the annual operating plan and avoiding the distraction of the day.   Audits, visiting committees, and even Joint Commission visits have the potential of creating attention deficits which derail IT staff from long term must do's.    I'm grateful that Joint Commission preparation has become such an integrated part of our standard work that no projects were derailed.

2.  Enterprise and Community interoperability
I'm often asked when interoperability will become a standard practice in communities.   In many Massachusetts institutions, data exchange is already happening and the state HIE is processing over a million transactions a month.   However, there are still gaps in offering hospital-based clinicians access to the EHRs of private practice referring physicians.   I outlined the work we're doing this Summer to ensure that opt-in consent to disclose is captured at referring clinician practices as this will enable us to complete the electronic linkage which provides 24x7x365 on demand data sharing.

3.  Annual Operating Plan update
IT has 5 goals in 2013 and I reviewed our progress on all of them
Meaningful Use Stage 2 - we have achieved all MU2 hospital requirements except Electronic Medication Administration Records/Bedside Medication Verification.   Our new EMAR/BMV application goes live in July and we are on track to have 10% of all medication orders processed through it for the October-December Meaningful Use reporting period.

ICD10 - our greatest challenges are clinical documentation improvement such that enough information is available to justify highly detailed ICD10 codes and outpatient coding strategies so that we do not need paper-based superbills hundreds of pages long for every clinic.   We're working with 2 established companies and one start up to create novel computer assisted coding workflows and real time documentation improvement, linking the act of documenting to the requirements for accurate billing in a single workflow.

Laboratory Information System - we go live with the pathology module in our new Laboratory Information System on August 2.  Integrated testing is going well.

ACO support - we've worked hard to generate all the data necessary for our ACO to produce the quality and financial performance reports required by CMS.   We finished our first year as an ACO with a positive margin.  

Compliance/Security - I presented the project plans for 14 work streams of security enhancements suggested by our recent security audit.   Improvements include network access control, security information and event management applications, and a comprehensive NIST 800 ongoing risk management program.

4.  Conversation Ready Project - As part of  the Joint Commission visit, we showed the reviewers screenshots for a new end of life preference documentation application we're building.   Our feeling is that structured data and metadata around end of life planning is not sufficient.   We need documents which reflect a deep conversation about preferences, so that it what we are creating.   Documents may be handwritten, faxed, typed, or natively electronic, so we need to support multiple document capture workflows.

5.  Patient and Family Engagement in ICUs Grant - We collaborating with a major private foundation to think about patient and family engagement in ICUs.   The Clinical IT Governance committee needed to understand the level of work and its alignment with our strategic plan, meaningful use, and compliance requirements.    I always discuss grant opportunities  with governance committees, because sometimes grants are not well aligned with existing work and become a costly distraction.    The committee asked many good questions about this grant opportunity and we're now poised to refine the workplan with the foundation leaders.

A very productive meeting.

HISP to HISP communications

As Massachusetts works through the details of building a trust fabric for health information exchange, we have been working through another set of challenges in HISP to HISP communication.

Meaningful use Stage 2 requires EHRs to support the Direct Project implementation guide, which uses SMTP/SMIME as a transport protocol.   Optionally, Stage 2 also supports XDR/SOAP.

In the world of standards, "OR" always means  "AND" for implementers.   Massachusetts needs to support HISPs that allow XDR as well as those which only allow with SMTP/SMIME.   This gets confusing when there is a mismatch between the sender's protocol and the receiver's protocol, requiring a HISP to convert XDR to SMTP/SMIME or SMTP/SMIME to XDR.

There are 4 basic scenarios to think through
1. An SMTP/SMIME sender to an SMTP/SMIME receiver
2. An SMTP/SMIME sender to an XDR receiver
3. An XDR sender to an SMTP/SMIME receiver
4. An XDR sender to an XDR receiver

Scenarios 1 and 4 could be done without a HISP at all if the EHR fully implements the Direct Standard including certificate discovery.

Cases 2 and 3 require thoughtful security planning to support end to end encryption between two HISPs.

These slides provide the detail of what must be done for Cases 2 and 3.  

The challenge of supporting XDR is that the HISP must act as the agent of senders and receivers, holding their private key for use in the conversion from/to SMTP/SMIME.

As Massachusetts continues to enhance its state HIE capabilities and connect many other HISPs (eClinicalWorks, Cerner, Surescripts, AthenaHealth etc) to state government users and those using the Massachusetts HISP as part of their EHR (Partners, BIDMC, Atrius, Tufts Medical Center, Meditech users, NextGen users etc.) we now know what must be done to provide end to end encryption among different HISPs and users connected via 2 protocol choices.

We're learning once again that optionality in standards seems like a good idea, but ultimately adds expense and complexity.
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Everyone on the HIT Standards Committee knows my bias - offer no optionality and replace the existing SMTP/SMIME and XDR approaches with RESTful APIs such as the Mitre hdata initiative.

Maybe for Stage 3!

Building Unity Farm - The Bees Arrive

On Saturday night 96,000 Italian bees arrived at Unity Farm in 8 hives.   What are Italian bees?   Here is an overview of bee types.
There are many subspecies of the honeybee, Apis mellifera.  Each has different characteristics in temperament, honey production, winter hardiness, swarming behavior, and disease resistance.    We chose Italians that had overwintered in Massachusetts for their lack of aggressiveness, consistent ability to produce honey, and their likelihood of reproducing sufficiently to sustain a stable population in our orchard and meadow.

Our Guinea fowl enjoy eating bees, so we created an elevated platform using oak pallets that ensures the hive entrances are higher than guinea mouth height.

To begin our bee journey, we placed 4 "nucs" or nucleus hives in the orchard and 4 nucs in the meadow near the stream.   A nuc is a fully functional starter hive consisting of a laying queen and bees on frames of brood, honey and pollen.  Soon these frames will be transferred to standard Langstroth hives which consist of combs hung in vertical sheets for easy honey harvesting and bee care.

At the moment, the bees are staying close the their hives, circling to get oriented to their new home.   They're very gentle and will land on me as I approach the hive.   I've not been stung and expect that we'll have a great long term symbiotic relationship.   The apple trees are in full bloom and pollen/nectar is plentiful in the orchard.   Similarly, wildflowers are abundant in the meadow, so all 8 hives are buzzing with food gathering activity.

During our first year as beekeepers, we'll be guided by Noah Wilson-Rich, Ph.D, a behavioral ecologist, a beekeeper, and the founder of Boston’s Best Bees.

In 2014, we'll evaluate our progress and think about adding bee care to our weekly farm tasks.

Some will debate if beekeeping is vegan.   Since no bees are harmed and the quality of life of the bee is not changed in any way by beekeeping, I believe it is consistent with vegan ideals.   The same cannot be said about the dairy industry or factory farmed chickens producing eggs.   Honey is not secreted by bees, it's the product of nectar mixed with bee digestive enzymes.

I look forward to our first honey harvest and comparing the characteristics of orchard honey to meadow honey.

Documenting End of Life Care Preferences

Following up on yesterday's post about ICU dashboards, I think it is equally important to document end of life care preferences in the electronic health record.   The HIT Standards Committee has been charged in 2013 with developing the standards for structured data capture of end of life care preferences.

At BIDMC, we've already designed an approach in conjunction with the Institute for Healthcare Improvement's Conversation Ready project.

Conversation Ready is a collaborative effort between the Institute for Healthcare Improvement (IHI) and a handful of "pioneer" institutions, of which BIDMC is one, to ensure that we're ready to 1. receive/elicit patients' goals of care or preferences, 2. record them in our systems, 3. retrieve them when needed, and thereby 4. do a better job respecting them.

As a healthcare system, the US is not currently very good at doing these things, and there is a strong push to get better. To that end, it is one of BIDMC's Annual Operating Goals to become Conversation Ready, and we have a large team working to do this, which includes: the Senior VP for Quality Improvement, the Director of Ethics and Palliative Care Programs the Medical Director of Inpatient Quality, the Director of Performance Assessment & Regulatory Compliance, the Director of Social Work and Patient/Family Engagement, Patient Advisors, Associate Chief Nursing Officer of Ambulatory & Emergency Services, a Palliative Care and HCA Primary Care Physician, and several IT professionals.

A BIDMC hospitalist is the project director, and a BIDMC communications manager serves as the project manager.  We've been meeting for about 5 months now, and in addition to the IT solutions presented in these slides, we're collecting stories and data to motivate conversations, as well as developing training modules, scripts and other materials to improve our ability have these conversations.

The slides reflect the team's preliminary vision of how to improve the way we record patients' wishes around end-of-life care and retrieve them when needed.  We believe that becoming "conversation ready" requires a centralized place to store this information which is accessible from all our clinical applications.  The slides also outline a system for managing PDFs of paper Advance Care Planning documents (e.g. Proxy forms, Advance Care Directives, letters to family members, DNR/MOLST forms) that would enable us to effectively store, update and retrieve them as needed, thus capturing all the work and time that were put into creating those documents and enhancing our ability to best respect our patients wishes.  Ultimately we hope that this Advance Care Planning data could become part of health information exchanges to ensure a shared mental model across care settings.

Reflecting on my father's recent experience with end of life care, such an approach would have ensured his wishes were widely understood and respected.

I look forward to the project.

Patient and Family Engagement in ICUs

My father died 2 months ago and now with a bit of distance from that emotional event, it's time to further reflect on technology to support patients and families in ICUs.

BIDMC has been speaking with a major foundation about creating a cross-disciplinary, multi-institutional, open source application to turn critical care data into wisdom for patients and families.

How might it work?  Let me use my father as an example.

My father had multiple sclerosis for 23 years, myelodysplastic syndrome for 2 years, and 3 myocardial infarctions since 2009.

When I arrived at his ICU bedside in early March, I spoke with all his clinicians to create a mental dashboard of his progress.   It looked something like this

Cardiac - history of 2 previous myocardial infarctions treated with 5 stents.   New myocardial infarction resulting in apical hypokinesis and an ejection fraction of 25%.   No further stent placement possible, maximal medical therapy already given.  

Pulmonary - New congestive heart failure post recent myocardial infarction treated with diuretics, nitroglycerine drip, afterload reduction, upright position, and maximal oxygenation via bilevel positive airway pressure.  O2 saturation in the 90s and falling despite maximal therapy (other than intubation)

Hematologic - failing bone marrow resulting in a white count of 1, a platelet count of 30, and a hematocrit of 20

Neurologic - significant increase in muscle spasticity, resulting in constant agitation.   Pain medication requirements escalating.  Consciousness fading.

Renal - Creatinine rising

Although I did not have realtime access to his records, I gathered enough data from my conversations to turn this dashboard into a scorecard green, yellow and red indicators.

Cardiac - Red due to irreversible low ejection fraction

Pulmonary - Red due to the combination of falling O2 saturation despite aggressive therapy

Hematologic - Red due to lack of treatment options available for myelodysplastic syndrome and an inability to transfuse given the low ejection fraction and congestive heart failure

Neurologic - Yellow due to the potential for successful symptom control with pain medications

Renal - Yellow due to treatment options available for renal failure

My father had expressed his wishes in a durable power of attorney for healthcare - do not intubate, do not resuscitate, no pressors,  no feeding tubes, and no heroic measures.

From the combination of the dashboard, scorecard, and his end of life wishes, it was clear that hospice was the best course of action.

I'm a physician with 20 years of practice experience.   I'm a CIO with 30 years of data analysis experience.   I'm a decision maker with 35 years leading teams.

Making the hospice decision required all of my skills.

Ideally, patients and families should have the tools  needed to make such decisions regardless of their medical sophistication.

Our proposed project is an automated ICU dashboard/scorecard for patients and families updated in realtime based on data aggegrated from the medical record and patient connected telemetry.    The architecture will be a decision support web service , Hospitals send data in and the web service returns the wisdom of a graphical display.

The project is ambitious and will bring together patients, providers, and IT experts.    We look forward to the challenge of creating a patient and family friendly dashboard for ICUs.    My healthcare navigator service to my father would have been empowered with such a resource.

Building Unity Farm - The Mushroom Farm Begins

Last weekend, my wife Kathy, Bill Gillis (CIO of the Beth Israel Deaconess Care Organization), and I completed 72 Oyster mushroom totems and 60 Shitake logs - about 10,000 pounds of wood requiring 3000 individual inoculations.

Here's how we did it.

I cut 72 two foot segments of poplar, 8 to 16 inches in diameter, from the trees we felled behind the house in the early spring when sap was flowing but leaves had not yet emerged.   This wood has the maximum amount of moisture possible.   Over the weekend, we cut each log into 2 one foot pieces plus a thin third piece.   I purchased 6 sub-species of oyster mushroom spawn.   First, we poured about a cup of spawn into the bottom of a thick black trash bag.  We placed the first log segment on top of the spawn.   We then added another cupful on top of that log and placed another log on top of it.  Finally we added another cupful and placed the thin third piece on top.   We closed the bag with a rubber band and stored each completed "totem" in the shade of a pine grove.    We inoculated 12 totems for each species.  The end result of 72 totems stacked in the forest is pictured below.

 After Labor Day we'll remove the bags and enable the inoculated logs to fruit.   We'll get some Oyster mushrooms this Fall, but the bulk of our first harvest will arrive next Spring.

For Shitake, I cut 220 four foot oak logs between 4 and 12 inches in diameter when clearing land for the orchard.   They were also harvested for maximum moisture.   I purchased 11 sub-species of shitake mushroom spawn.  Over the weekend we placed a log in the wheels of the assembly line we designed, drilled 12mm holes 1.5 inches deep every 6 inches along the log, and repeated the pattern every 2 inches around the circumference.

We used inoculator tubes to place spawn in each hole, then sealed it with cheese wax heated to 400 degrees F.   We carried the finished logs to the shade house (85% shade cloth) and stacked them lincoln log style.

We have room for 11 stacks of 20 logs.   We did 60 last weekend and will do another 60 this weekend.     By the time we're done, we'll have drilled and filled 10,550 holes.

Next Spring we'll move the logs from stacks to leaning upright in the forest.  Like the Oyster mushrooms we may get some fruiting this Fall but the bulk will be next Spring.

These logs will produce for years to come and our hope is to start a mushroom community supported agriculture program (CSA) once we've proven our ability to produce large quantities of high quality mushrooms.

Making progress.