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!

The December HIT Standards Committee

The December HIT Standards Committee focused on patient generated data, image sharing, patient matching, and the 2014 work plan, ensuring we select the necessary standards to support Meaningful Use stage 3 policy goals.

We began the meeting with a discussion by Leslie Kelly-Hall of patient generated healthcare data - structured and unstructured questionnaires plus patient provided medical history such as medications, allergies, and problems.      The key discussion was an evaluation of the standards maturity and the level of adoption of the standards suggested for patient generated data exchange.  Recommendations included Direct for data transport, CCDA for content capture, LOINC/SNOMED for vocabulary capture, and Continua implementation guides for devices.   As a followup the Consumer Technology Workgroup will list examples of CCDA templates that can be used to support patient generated data use cases.   Continua will provide us a list of the named standards so that we can validate the maturity and adoption of Continua's implementation guides.  We will also ensure that the CCDA templates include the appropriate vocabularies that will  enable incorporation of patient generated data into EHRs.

Next, Jamie Ferguson presented an overview of the standards selected for radiology and non-radiology image exchange, including associated reports.  Our challenge was to provide a parsimonious collection of constrained standards for consumer and professional applications in tightly coupled (modality to PACS), and loosely coupled (web-based, cloud hosted image exchange) architectures.   We all agreed that we need to be very careful when writing certification criteria to avoid optionality such that vendors will be forced to implement many different standards (the "OR" of meaningful use becomes the "AND" of certification).

Next, Lee Stevens presented the work done to date on Patient Matching. We all look forward to ONC's final recommendations for optimizing data quality, selecting matching algorithms (deterministic or probabilistic), and choosing data elements that will provide reasonable sensitivity and specificity.

Finally Doug Fridsma a straw man plan for reorganizing the HITSC workgroups, spreading the work ahead across more people to enhance our agility and reduce volunteer burn out.   All thought  the reorganization and work plans were reasonable but suggested two additions.  First, we'll need another workgroup that focuses on research/creating a learning healthcare system.   Second, we need to ensure that each workgroup reserves time for future planning and does not limit its scope to selection of incremental standards to solve today's urgent needs.  We'll implement future planning by adding it to each workgroup's agenda and implementing a matrixed management approach for communication and coordination of future planning among the workgroups.

The FY14 work ahead looks well prioritized and categorized.   Our next meeting will be in February when we'll be joined by the new National Coordinator for Healthcare IT, Karen DeSalvo 

Become a Mountain

When I was 16 years old I wrote a short collection of poems.   The cover page listed a few youthful notions that would become my life long guiding principles:

"Be wary of artificial limits and self-compromise
If the world praises mediocrity, don't seek praise
Be true to yourself
You make your own destiny"

Some of these ideas were written in response to high school teachers who told me that my goals were unachievable - I should not ask "will I" but "can I".

Over my career, I've worked with and for many people.   Along the way I've encountered many styles - those who lead by intimidation, those who lead by collaboration, and those who lead by inspiration.   Some have asked me to stretch my limits and others have asked me to constrain them.

When I recently reviewed the words I wrote at 16, I reaffirmed that at my core is the notion that I should live each day to the fullest, performing at what I consider the very edge of my capabilities, then add one more thing.    It's the motivational equivalent of "no pain, no gain".

My wife recently sent me a quote that summarizes this passion even more eloquently:

"I am here for a purpose and that purpose is to grow into a mountain, not to shrink to a grain of sand. Henceforth will I apply all my efforts to become the highest mountain of all and I will strain my potential until it cries for mercy.  Og Mandino"

When I was resident in emergency medicine in Los Angeles, I was on the front line during some of the most violent years in gang-related shootings.    It was the era before residency duty hour limits and I recall one particularly rough weekend on the trauma service that required 36 hours in the operating room.    I became so dehydrated that my urine crystalized and formed kidney stones.    I'm not suggesting this was a good thing or should ever occur during residency, but it does illustrate the potential of the human will during a crisis.

A few years ago, my daughter read a short story by Kurt Vonnegut called Harrison Bergeron  (it was also made into a short film called 2081) in which absolute equality was achieved by putting weights on athletes, loud earphones on academics, and masks on beautiful people, artificially limiting their performance.

Sometimes we encounter this in our work lives with less dramatic but real suggestions that we perform at a level below our capabilities.

My advice - you'll encounter many people in life who feel more comfortable when surrounded by grains of sand.   However, in a humble, quiet, and selfless manner, become a mountain.   Stretch yourself beyond any internally or externally induced self-compromise and limits.

We only live once and no one has ever put this on their tombstone:

Building Unity Farm - Herd Health

One weekend each month, Kathy and I do "care management" and "population health" for the 100 animals of Unity Farm.  Here's the workflow:

Llamas/Alpacas
We gently halter each animal and reassure them by rubbing their chins and scratching their ears.   After a year with us, we've gained their trust.   Many of the animals nuzzle and tuck their heads into our necks, as if to say "Dad, do I really have to go to the doctor?".   We then lead each one to the floor scale where we weigh them, looking for monthly variation.   Do they have an infection or parasitic issue that is causing weight loss?  Have they been eating too much, putting on too much weight?   There is no "body mass index" for camelids, so we assess their body score, which is a measure of fat thickness in the hindquarters.   After weighing, we subcutaneously inject Ivermectin to prevent meningeal worm (transmitted from deer to alpaca via snails ingested accidentally from grass).    Then we trim toenails.   Orchid, our guard llama, weighs 317 pounds.   Imagine trimming the nails on a 317 pound two year old.   We reassure each animal, then explain what we are about to do by saying "foot".   I support their body weight with my legs and gently raise each foot to trim the nails, repair any cracked nails, and clear each foot pad of mud and debris.    Finally, we check ears and eyes to ensure there are no signs of infection or trauma.   We do this for 12 animals in about 3 hours.   Once a year at shearing time we also file their teeth if needed.

Chickens/Guinea Fowl
We examine each bird for signs of parasitic infections (loss of feathers or weight), trauma from "hen-pecking", irritation from egg laying, skin damage from cold exposure, and orthopedic injuries from running free range throughout the farm property.   We ensure they have a source of grit for digestion and calcium for strong egg shells.   We clean their coop thoroughly, scrubbing their water sources and removing any droppings from roosting areas.  

Ducks
We examine their web feet for irritation, their feathers for parasites, and their eyes for any signs of infection.   We scrape out their pen and freshen the sand/gravel.  We replace the straw in their duck house and scrub all their water sources, including their stock pond.

Dogs
We examine their entire bodies for ticks, hot spots, signs of cold damage, trauma from rough play, and their dental health.   They are fully vaccinated for Leptospirosis, Coronavirus, Lyme, and Rabies.

Rabbits
Just as with the other animals, we look for signs of weight loss, dermatologic issues, and eye infections.  We feed papaya enzyme tablets to reduce hairballs.

2013 has been a great year for the animals.   We lost one chicken from a hawk attack and one rabbit from old age.   We hope that Unity Farm has created the same stress free environment for the animals that it has for us.

Google Glass Progress Report

Our teams continue to work on Google Glass applications for Emergency Department workflow improvement.   Here's a photo of our team at work with a stealthy startup developing healthcare solutions on Google Glass.

Issues we've had to address include decision making about thin client web versus thick client functionality, enabling a persistent secure network connection, and ensuring secure data flows through servers.

At the moment we are optimizing the user experience and beginning our study design to record patient reactions and clinician experiences.

If patients object we will not use Glass for their encounter.  Quantifying patient reactions will be very useful.  We are still working out how we will do this.

I'll report back as soon as we have experience in actual use.

Meaningful Use and Certification Improvements

Today, HHS circulated the following important announcement:

"CMS to Propose New Timeline for Meaningful Use Implementation and ONC to Propose New Regulatory Approach to Certification

I wanted to make sure you were aware that the Centers for Medicare & Medicaid Services (CMS) today proposed a new timeline for the implementation of meaningful use for the Medicare and Medicaid EHR Incentive Programs and the Office of the National Coordinator for Health Information Technology (ONC) proposed a more regular approach to update ONC’s certification regulations.

Under the revised timeline, Stage 2 will be extended through 2016 and Stage 3 will begin in 2017 for those providers that have completed at least two years in Stage 2. The goal of this change is two-fold: first, to allow CMS and ONC to focus efforts on the successful implementation of the enhanced patient engagement, interoperability and health information exchange requirements in Stage 2; and second, to utilize data from Stage 2 participation to inform policy decisions for Stage 3.

The new regulatory approach to certification that ONC is proposing would allow for certification criteria to be updated more frequently under the ONC HIT Certification Program. This approach is designed to provide public input on policy proposals, enable our certification processes to more quickly adapt to include newer industry standards that can lead to greater interoperability, and add more predictability for EHR technology developers. We also anticipate that this new approach would spread out over a longer time period the certification requirements to which EHR technology developers have previously had to react.

More information is available at www.healthIT.gov/buzz-blog"

There has been some misinterpretation of this text, so it's important to clarify what it means.

This is NOT a delay of Meaningful Use in 2014 (Stage 1 or Stage 2).   All 2014 certification and attestation deadlines are still in force.  

This announcement adds another year to Stage 2, delaying Stage 3 to 2017 and making Meaningful Use Stage 2 a three year cycle. 

The federal government does things methodically.  Though it may seem that this decision is lower priority than addressing 2014 issues, it needed to happen now.  Since Marilyn Tavenner messaged at HIMSS that there would be "no rule making in 2013," the timeline established in previous regulations had Stage 3 beginning in 2016, which would have ONC and CMS releasing proposed regulations now.

The fact that today's announcement did not address 2014 issues does not imply that no one is listening to those concerns.  Some may complain that they were expecting lunch and dinner but only got lunch.  It's fair to say that lunch comes before dinner.

The second part of the announcement about certification is a good thing for developers of EHR technology.

ONC is starting a new iterative process of certification that will allow ONC to "telegraph the pass" as Acting National Coordinator Jacob Reider said today - giving developers advance warning of functionality that will be expected in subsequent iterations of the certification program, enabling feedback on such intentions very early, and facilitating adoption of new standards/new versions of standards.  Developers will be able to evolve their products as standards evolve, rather than maintaining alignment with old standards that are part of stale certification criteria.  

In summary, today's announcement is a first step in the fine-tuning of the national healthcare IT timeline.  Stage 2 is now a three year cycle beginning in 2014, Stage 3 begins in 2017, and the certification program moves from a waterfall approach to an agile approach.   In the table below, the three's in the 2016 column become two's, without any changes to 2014.

This is important progress and should be welcomed as a sign that HHS is listening.   There is still work to do and I look forward to continued refinements over time.

Building Unity Farm - Preparing for Winter

Snow will begin falling in New England over the next few weeks.    Most nights have subfreezing low temperatures and it's challenging to maintain water sources for the animals and plants on the farm.

How do we do it?  Heated buckets, heated troughs, heated poultry waterers, heating panels, and yard hydrants.

Here's how it all works:

Ducks - ducks are very resilient to cold and enjoy living outside, only retreating to the duck house in the most severe weather.    Within their pen, the ducks have a heated 50 gallon stock tank/water trough and a heated poultry waterer.   Both activate at 35F.  In the duck house, the ducks have a safe Infratherm heating panel which raises  the temperature of the space by 10F and is activated by a 35F on/45F off Thermocube.  Never use a heat lamp to heat a coop.  Every winter, stories abound about unnecessary coop fires.

Chickens - the chickens are also resilient to cold but prefer to roost inside the coop on very cold or windy days.   They have a poultry water heater (activated at 35F), a heated 5 gallon bucket "nipple waterer" which includes 4 small drinking spigots, and 4 infratherm heating panels that raise the temperature of the coop 10 degrees F.

Alpaca/Llama/Dogs - they have 5 gallon heated buckets (activated at 35F)

Hoop House and Barn water - we use yard hydrants which are supplied from pipes buried 4 feet deep below the frost line.  This enables us to fill buckets and water plants even in the coldest part of winter.

We have 350 bales of hay in the loft, 4 tons of alfalfa in the barn, 300 pounds of poultry grain in waterproof cans and 300 pounds of ice melter (animal safe magnesium chloride).

Let it snow!

Commanding Versus Leading

When I first became a CIO, my role involved writing applications and managing architecture at a detailed level.   Over the past 17 years, my role has become much more strategic, ensuring the right investments in the right overall architecture are made with appropriate resources to support them.    I've had to master the political, communication, and interpersonal skills of leading rather than the technical skills of being a strong individual IT contributor.   Although the way, I've learned the difference between Commanding and Leading.

In an academic health center, formal authority is rarely exercised.   The ability to get things done (or not done) depends upon reputation, trust, and personal influence.    The greatest leadership I challenge I face in 2013-2014 is that the plate is overfilled with ICD10, MU2, HIPAA Omnibus Rule, and the Affordable Care Act.   The majority of my leadership efforts involve getting the entire organization to focus on the regulatory must dos, while deferring nice to haves.   I do this because it is the right thing to do for the institution, but equally important is to triage work away from my staff, which are at the breaking point because of too many demands.

Budgets over the next year at most hospitals are not likely to enable the hiring of new resources beyond those needed for ICD10, HIPAA related security updates, and ACA related analytics.   My leadership task is to limit work to the right work, attempting to buffer my staff from the mayhem of competition for scarce IT resources.

With all the tensions and anxieties involved in running governance committees, planning efforts, and communication outreach, what drives me to do it?

I recall reading a quote from General Shinseki about his views on leadership from his retirement message in 2003:

"You must love those you lead before you can be an effective leader. You can certainly command without that sense of commitment, but you cannot lead without it."

I have maintained my role at BIDMC for 17 years because of loyalty, admiration, and affection for my staff.   I've encountered many leaders who do not understand loyalty and are driven by fame, fortune, or the next new thing.    I'm hopeful that my devotion to staff helps with creating a positive culture, reduces turnover, and builds informal authority - a sense that we're all in this together, fighting important battles every day.

Top down command and control works in some organizations and some industries.   Some employees in organizations which thrive on command and control have told me that they work with constant fear of failure/criticism.   My hope is that leadership built on the the strength of employee relationships creates a joy of success motivation without fear.   Whenever bad things happen, and they do, we should ask how our work processes enabled the mistake, celebrating the learning and not blaming the individual.

When I was young, I thought that management meant authority, power, and self-reliance.   Over time, I've learned that management is about relationships, collaboration, and creating a community of people who support each other.   Leading a team of people you admire is much more satisfying than commanding and that's why I'm still a CIO.