For more photos, see our Unity Farm Alpacas Facebook site.
Saturday, August 18, 2012
Thursday, August 16, 2012
Joyful Chaos
In past personal blogs about our cancer journey, I've explained the "why" - looking forward to a vision of a bucolic future made the six months of cancer treatment a lot more tolerable.
Ive never explained the "how". In a new series of Thursday blogs, beginning today, I'll recount what we've done and what we're doing to turn 15 acres of Sherborn, Massachusetts into a productive working farm providing a non-stressful environment numerous animals and a nurturing ecosystem for a bountiful fruit/vegetable harvest.
The property we purchased in April 2012 has all the right ingredients - former pastureland filled with 1700's rock walls, flat sunny well drained soil with generous sun exposure, forest, a meadow, and a stream/wildflower wetland.
Over the past hundred years, the pastures have filled with second growth trees - pines, oaks, and black birch. The rock walls have been lost in a sea of bittersweet, wild grape, and poison ivy.
Our first task was re-open the pastures. We cleared over 50 trees including numerous invasive/non-native plans. We used an expert tree contractor for the large trees and for the smaller trees I used a Stihl MS290 chainsaw, a Gransfors Bruks splinting maul/Swedish forest axe, and a steel farm push cart capable of hauling 800 pounds.
Our next task was to clear debris - fallen branches and deadwood. I created a pile 50 feet long and 10 feet high, which we chipped into mulch.
Then we created paths throughout the property which enabled us to manage the land. We covered the paths with the mulch we created from chipping.
Once the rough clearing was done we had to move rocks. New England is full of rocks. Although I hand carried many and used a heavy duty wheelbarrow for others, we used a small front loader (Bobcat) for the really large ones.
Once the topography of the land was more obvious, we planned our planting areas, buildings and fences.
A wetland engineer is working with the town of Sherborn to plan our future planting areas - likely an orchard of heirloom apples and a meadow filled with high bush blueberries.
We created a 10x12 chicken coop and a loafing shed to keep animals warm in winter/cool in summer. We planned 1000 feet of fences and chose to use 5 foot woven wire fence supported by posts at 20 foot intervals, topped by a hot wire (9000 volts, low amperage) to keep the predators out.
The end result was 2 quarter acre paddocks - one for males and one for females, and a half acre pasture, connected with a series of 8 gates that support manure management, hay storage, and easy movement of animals.
We then planned the barn. The property included a barn, but it was originally designed as more of a garage than a barn. We added hay loft doors, thick rubber mats for the stalls, a water hydrant with a french drain, fans to keep animals cool in Summer, and wall mounted feeders. We painted the building red with black trim and added barn lights above each door.
With this layout done, we had the infrastructure in place to complete our animal strategy. We raised 12 chickens from 3 day old chicks indoors and moved them to the coop at 6 weeks. A friend gave us a rooster. We named him "Lucky" since he'll be living with vegans/vegetarians.
We raised 22 guinea fowl from 3 day old chicks and moved them to the coop at 6 weeks.
By pure happenstance, my Telecom manager is selling her herd of 8 alpaca. After meeting them, we purchased the entire herd - 3 males and 5 females.
Realizing that alpacas need guardians because they do not defend themselves well against the coyotes, fisher cats, and other predators on our property, we researched llamas. We found an ideal guard llama who has lived with alpaca for many years. She also happens to be pregnant.
The female llama will guard the female alpaca.
For the male alpaca, we chose an experienced female Great Pyrenees mountain dog, the livestock guardian used by Basque shepherds. We also chose a male Great Pyrenees puppy who will keep the female company and learn how to guard from her.
On August 18, the alpaca arrive. On August 20, the female Great Pyrenees arrives. On August 23, the male Great Pyrenees arrives. On August 26 the llama arrives.
The journey of joyful chaos at Unity Farm has replaced the cancer journey and our property is about to blossom with new arrivals.
Wednesday, August 15, 2012
The August HIT Standards Committee
The August HIT Standards Committee focused on criteria to assess standards maturity, concerns about the timing of the Meaningful Use 2014 edition final rule, further work on the national curated vocabulary and code set repository, and an important discussion about future ONC S&I framework efforts.
Dixie Baker presented the final recommendations of the NwHIN Power Team regarding the objective criteria used to assess the maturity of standards. Her framework was very well received. The Standards Committee will draft a formal letter of transmital to ONC suggesting that these criteria be applied when addressing and ONC or HIT Standards/HIT Policy Committee questions about standards readiness. Jim Walker offered a friendly amendment that these criteria are so good they could be used as an effective tool for predicting the future success of a new national standard. Given the current discussions by the Policy Committee's Meaningful Use Workgroup which is finalizing Stage 3 recommendations based on the future maturity of standards, all agreed that these maturity criteria should be used by HITSC workgroups to answer HITPC questions. Over the next month, we will use the criteria to respond to the Meaningful Use workgroup's latest requests for future standards availability.
Liz Johnson presented the work of the Implementation Workgroup, expressing the best thinking of those in operational settings who need to address software acquisition, installation and training by October 1, 2013 to meet Meaningful Use Stage 2 timelines. After much discussion we agreed that the discussion of our concerns in the Standards Committee was sufficient communication to ONC. Hopefully, the final rule will be issued very soon and the contingency plans we outlined will not be required.
Jim Walker presented an update on the foundational work being done by the National Library Medicine to create a national vocabulary and code set resource in support of meaningful use data exchanges and quality measures. The Standards Committee will continue to offer their support, advice and encouragement to the NLM efforts.
Finally, Doug Fridsma answered many committee questions about the S&I framework and current initiatives. Once the FY13 ONC budget is finalized, the HIT Standards Committee will offer its advice how use those limited resources in the most efficient way possible to accelerate standards availability for future versions of Meaningful Use. Doug will update the Committee about Meaningful Use Stage 2 testing and certification criteria in September. Carol Bean noted that ONC will soon authorize the permanent certification bodies to begin their work.
We all look forward to seeing the final rule and continuing our focus on the necessary details to ensure the success of Meaningful Use stage 2 and 3 interoperability efforts.
Dixie Baker presented the final recommendations of the NwHIN Power Team regarding the objective criteria used to assess the maturity of standards. Her framework was very well received. The Standards Committee will draft a formal letter of transmital to ONC suggesting that these criteria be applied when addressing and ONC or HIT Standards/HIT Policy Committee questions about standards readiness. Jim Walker offered a friendly amendment that these criteria are so good they could be used as an effective tool for predicting the future success of a new national standard. Given the current discussions by the Policy Committee's Meaningful Use Workgroup which is finalizing Stage 3 recommendations based on the future maturity of standards, all agreed that these maturity criteria should be used by HITSC workgroups to answer HITPC questions. Over the next month, we will use the criteria to respond to the Meaningful Use workgroup's latest requests for future standards availability.
Liz Johnson presented the work of the Implementation Workgroup, expressing the best thinking of those in operational settings who need to address software acquisition, installation and training by October 1, 2013 to meet Meaningful Use Stage 2 timelines. After much discussion we agreed that the discussion of our concerns in the Standards Committee was sufficient communication to ONC. Hopefully, the final rule will be issued very soon and the contingency plans we outlined will not be required.
Jim Walker presented an update on the foundational work being done by the National Library Medicine to create a national vocabulary and code set resource in support of meaningful use data exchanges and quality measures. The Standards Committee will continue to offer their support, advice and encouragement to the NLM efforts.
Finally, Doug Fridsma answered many committee questions about the S&I framework and current initiatives. Once the FY13 ONC budget is finalized, the HIT Standards Committee will offer its advice how use those limited resources in the most efficient way possible to accelerate standards availability for future versions of Meaningful Use. Doug will update the Committee about Meaningful Use Stage 2 testing and certification criteria in September. Carol Bean noted that ONC will soon authorize the permanent certification bodies to begin their work.
We all look forward to seeing the final rule and continuing our focus on the necessary details to ensure the success of Meaningful Use stage 2 and 3 interoperability efforts.
Tuesday, August 14, 2012
An Alternative HIE Architecture
Massachusetts has created a three year, three phased HIE plan based on "pushing" records from place to place, creating analytic repositories, and "pulling" data from providers based on a centralized consent repository/ master patient index. Here's a brief overview from an NPR broadcast yesterday.
We all want to solve the "Unconscious in the Emergency Department problem" which requires states/regions to build significant supporting components including a registry of all the healthcare institutions which a patient has visited and opted in for disclosure of records. Massachusetts has the funding and alignment of stakeholders needed to make this happen.
However, many states will not be able to create consent repositories and record locator services. Is there another approach that does not require significant centralized infrastructure?
BIDMC has created such a "pull" data exchange with the Social Security Administration.
Here's how its works:
The transaction was designed to be as simple as possible.
Social Security identifies themselves via a secure certificate and is considered a trusted partner. Then, Social Security computers send a secure SOAP request, including a scan of the patient's signed medical record release document and patient identifiers to servers at BIDMC. We store the patient release document in our logs. We look up the patient in our system and if we can reliably match the patient using multiple identifiers, we create a CCD/C32 (Summary of Care document) and return that to the Social Security computers via the secure SOAP response.
The transaction is a query/response model without any centralized infrastructure.
Since there are no widely implemented standards for consent data, we're using something simple - a TIFF that is a scan of the patient release document and patient identifiers.
No human reviews these TIFFs during the initial record exchange - the patient release document is stored and the response is sent immediately. If a question about the release arises, we have the original signed scan and audit trails to review.
The C32 document is sent via a secure, encrypted, session back to the Social Security Administration. If the session concludes successfully, then the document was received.
Thus, it is possible to "pull" records from an outside institution without any centralized indexes or registries - just send a scan of the consent with the electronic query for records.
Admittedly a statewide master patient index that includes consent to disclose records from specific institutions will scale better and enable targeted retrieval of data from each location where a patient has data, but for those who want a query response approach for retrieval of data from a specific institution, the Social Security Administration approach works well.
We all want to solve the "Unconscious in the Emergency Department problem" which requires states/regions to build significant supporting components including a registry of all the healthcare institutions which a patient has visited and opted in for disclosure of records. Massachusetts has the funding and alignment of stakeholders needed to make this happen.
However, many states will not be able to create consent repositories and record locator services. Is there another approach that does not require significant centralized infrastructure?
BIDMC has created such a "pull" data exchange with the Social Security Administration.
Here's how its works:
The transaction was designed to be as simple as possible.
Social Security identifies themselves via a secure certificate and is considered a trusted partner. Then, Social Security computers send a secure SOAP request, including a scan of the patient's signed medical record release document and patient identifiers to servers at BIDMC. We store the patient release document in our logs. We look up the patient in our system and if we can reliably match the patient using multiple identifiers, we create a CCD/C32 (Summary of Care document) and return that to the Social Security computers via the secure SOAP response.
The transaction is a query/response model without any centralized infrastructure.
Since there are no widely implemented standards for consent data, we're using something simple - a TIFF that is a scan of the patient release document and patient identifiers.
No human reviews these TIFFs during the initial record exchange - the patient release document is stored and the response is sent immediately. If a question about the release arises, we have the original signed scan and audit trails to review.
The C32 document is sent via a secure, encrypted, session back to the Social Security Administration. If the session concludes successfully, then the document was received.
Thus, it is possible to "pull" records from an outside institution without any centralized indexes or registries - just send a scan of the consent with the electronic query for records.
Admittedly a statewide master patient index that includes consent to disclose records from specific institutions will scale better and enable targeted retrieval of data from each location where a patient has data, but for those who want a query response approach for retrieval of data from a specific institution, the Social Security Administration approach works well.
Monday, August 13, 2012
The People Behind the Massachusetts HIE
I'm back! Sorry for the 10 day gap in blog posts, but given a limit of 168 hours in a week and the need prepare my father-in-law's home for sale in early September and ready Unity Farm for the August 19 arrival of 8 alpaca, 2 llama, and a Great Pyrenees livestockgGuardian dog, my evening writing time has been compromised. On Thursdays I'll begin a new personal series describing our life on the farm now that cancer treatment is over - "Building Unity Farm" starts later this week.
Although August is usually a time of vacations and downtime before the post labor day acceleration of projects, this August has been filled with Massachusetts Health Information Exchange policy and technology work in preparation for the October 15, 2012 "golden spike" which will eliminate silos of healthcare data in Massachusetts by connecting numerous early adopter provider organizations via the state's HIE backbone.
I've long believed that HIE is more about psychology and personality than policy and technology. You need the trust of the community and passionate people to make it happen.
Here's a primer on the most important people driving HIE in Massachusetts:
Manu Tandon is a unique public servant He's the CIO of the Executive Office of Health and Human Services (EOHHS) and is more interested in making a difference than fame or fortune. He's had a distinguished career in industry but chooses to serve the state government because he believes in the mission. He works tirelessly, sending emails at all hours of day and night. He's always connected and communicating with all our stakeholders inside and outside of government. He's that rare public servant who combines political savvy, transparency, and competency. Every stakeholder in the community trusts him and his position in government enables him to move projects forward rapidly.
Several folks are helping Manu Tandon work his magic. John Kelly, formerly of Harvard Pilgrim, is serving an influential architecture role at EOHHS. Venkat Jegadeesan creates the detailed specifications and requirements. Ray Campbell, CEO of the Massachusetts Health Data Consortium has helped create agreements and legal documents.
Micky Tripathi is a national treasure. He's the CEO of the Massachusetts eHealth Collaborative and chair of the HIT Policy Committee's Health Information Exchange workgroup. His domain knowledge of EHR and HIE is unique. His ability to communicate complex policies and project details is unmatched. The presentations that led to industry, academic and government support of the Massachusetts HIE were authored by Micky.
Laurance Stuntz is both a leader and a technologist. He's the new Executive Director of the Massachusetts eHealth Institute (MeHI) and was the architect of the New England Healthcare Exchange Network (NEHEN). He's also trusted by all the stakeholders. He can assemble an understandable budget with the same competency as editing a Web Services Definition Language (WSDL) specification for an HIE interface.
Dr. Larry Garber is an informatics powerhouse, creating strategy, writing code, and implementing bold pilots.
The maturity of the standards and the incentives of meaningful use have helped accelerate HIE in Massachusetts. The 90/10 matching funding from Medicaid was a catalyst. But the real secret of Massachusetts momentum is the people. It takes a village to make HIE happen and we're blessed with a superlative team that creates miracles every day.
I'm proud to be a part of it.
Monday, August 6, 2012
The Open Source Electronic Health Records Agent Conference
In 2011, I joined the Board of OSEHRA, a nonprofit organization dedicated to innovation in electronic health record software. Founded in 2011, OSEHRA supports an open, collaborative community of users, developers, and researchers engaged in advancing electronic health record software and related health information technology. OSEHRA hosts software repositories for applications such as the VA’s and DoD’s EHR systems. For more information, visit the OSEHRA website .
On October 17 and 18, 2012, OSHERA will host its First Annual Open Source EHR Summit & Workshop. The Summit brings togethers stakeholders who support the use of open source electronic health record (EHR) technology and will be held October 17 and 18, 2012, at the Gaylord National Resort & Convention Center in Washington DC (National Harbor, MD).
The Summit will feature more than 30 panelists and speakers, including government officials, health care leaders, clinical care providers and policymakers. The event will bring together the OSEHRA community, now totaling more than 1,000 members, for the first time and provide a venue for Open Source Health IT training and educational workshops.
Conference topics will include:
Open source initiatives in Federal agencies; VA, DoD, HHS and others
Best practices in open source software development
Lessons learned from related industries
Open source software development in health care
Trends in the open source software industry
New open source initiatives
It is projected that within the next few years more than 200 hospitals and 1000 clinics within the federal sector will be managing and maintaining their EHRs using open source software. Open Source electronic health records are also being used in numerous domestic community health care facilities and more than 13 foreign countries. An increasing number of state agencies and private sector health care communities facing high costs of health IT have started calling for alternate approaches to traditional proprietary electronic health records. These open source activities create a significant market opportunity for both private and public sectors.
The Summit is now accepting abstracts for presentations addressing technical, business and policy issues associated with open source software and EHR. Abstracts are limited to 100 words or less and submission requirements are detailed at the conference registration site’s “Call for Papers” tab. The deadline for submission is August 24, 2012. To submit an abstract for consideration, please respond directly to summitabstracts2012@osehra.org.
I hope to see you there!
On October 17 and 18, 2012, OSHERA will host its First Annual Open Source EHR Summit & Workshop. The Summit brings togethers stakeholders who support the use of open source electronic health record (EHR) technology and will be held October 17 and 18, 2012, at the Gaylord National Resort & Convention Center in Washington DC (National Harbor, MD).
The Summit will feature more than 30 panelists and speakers, including government officials, health care leaders, clinical care providers and policymakers. The event will bring together the OSEHRA community, now totaling more than 1,000 members, for the first time and provide a venue for Open Source Health IT training and educational workshops.
Conference topics will include:
Open source initiatives in Federal agencies; VA, DoD, HHS and others
Best practices in open source software development
Lessons learned from related industries
Open source software development in health care
Trends in the open source software industry
New open source initiatives
It is projected that within the next few years more than 200 hospitals and 1000 clinics within the federal sector will be managing and maintaining their EHRs using open source software. Open Source electronic health records are also being used in numerous domestic community health care facilities and more than 13 foreign countries. An increasing number of state agencies and private sector health care communities facing high costs of health IT have started calling for alternate approaches to traditional proprietary electronic health records. These open source activities create a significant market opportunity for both private and public sectors.
The Summit is now accepting abstracts for presentations addressing technical, business and policy issues associated with open source software and EHR. Abstracts are limited to 100 words or less and submission requirements are detailed at the conference registration site’s “Call for Papers” tab. The deadline for submission is August 24, 2012. To submit an abstract for consideration, please respond directly to summitabstracts2012@osehra.org.
I hope to see you there!
Friday, August 3, 2012
The Massachusetts HIE Procurement
I've written several blog posts about the Massachusetts HIE strategic and operating plan to implement a statewide backbone for connecting every stakeholder in the Commonwealth.
All procurements have been done and we can now share the selection with the public. Here are the service providers we have chosen:
Direct Gateway - Orion
Access and Identity Management System (AIMS) - Cognosante (Sub Contractor to Orion)
Provider Directory - Initiate (Sub Contractor to Orion)
Clinical Gateway (HL7 interfaces to EOHHS/DPH) - Orion
Children’s Behavioral Health Initiative – HL 7 Interface - Orion
Syndromic Surveillance – HL 7 Interface - Orion
Healthcare Provider Portal (Part of Direct Gateway) - Compass (Sub Contractor to Orion)
Local Access Network Distribution (LAND) - Orion
Public Key Infrastructure (PKI) SaaS - Symantec (Sub Contractor to Orion)
Hosting services in a private MA HIE cloud - Logicworks (Sub Contractor to Orion)
Technical Support –(includes Call center) - Orion
Business Support – Operations and Maintenance - Orion
The Gateway, Provider Directory, and PKI infrastructure will go live on October 15, 2012. The additional services will go live in December 2012.
We believe that our System Integration vendor, Orion, has substantial US and international experience with Public HIE implementations. Their centralized cloud hosted gateways keep costs low and agility high. For those clinicians using non-certified or non-Direct compliant EHRs, Orion will provide and manage a low cost appliance in office settings to enable participation in bidirectional data sharing. Initiate has rich experience with directories and query interfaces to directories, both patient and provider. Symantec (which acquired Verisign) has thousands of public key infrastructure customers. The combination of Orion, Initiate and Symantec seems highly credible to us.
We have completed an analysis of every EHR deployed in Massachusetts and discovered that we can connect 80% of our stakeholders (including Long Term Care and Behavioral Health) by creating HIE interfaces for:
•Meditech
•LMR (Self developed at Partners Healthcare)
•Cerner
•Allscripts
•eClinicalWorks
•GE
•WebOMR (Self developed at Beth Israel Deaconess)
•Siemens
•Epic
•NextGen
•athenahealth
•Quest Care360
•E-MDs
•Point Click Care
•Netsmart Technologies
•UNI/CARE Systems
The Massachusetts eHealth Institute (MeHI) Last Mile Management Office will hire a System Integrator to manage interface development and the selection of implementation optimizing organizations to manage interface implementation and training.
With capital funding in place, a sustainable operating budget with public/private contributions, and strong vendors, we are confident the Massachusetts Statewide HIE will leverage Federal Standards to connect payers, providers, and patients in empowering ways. I'll write many additional posts describing the technology and policy decisions we make along the path to our October go live.
Truly the perfect storm for innovation.
All procurements have been done and we can now share the selection with the public. Here are the service providers we have chosen:
Direct Gateway - Orion
Access and Identity Management System (AIMS) - Cognosante (Sub Contractor to Orion)
Provider Directory - Initiate (Sub Contractor to Orion)
Clinical Gateway (HL7 interfaces to EOHHS/DPH) - Orion
Children’s Behavioral Health Initiative – HL 7 Interface - Orion
Syndromic Surveillance – HL 7 Interface - Orion
Healthcare Provider Portal (Part of Direct Gateway) - Compass (Sub Contractor to Orion)
Local Access Network Distribution (LAND) - Orion
Public Key Infrastructure (PKI) SaaS - Symantec (Sub Contractor to Orion)
Hosting services in a private MA HIE cloud - Logicworks (Sub Contractor to Orion)
Technical Support –(includes Call center) - Orion
Business Support – Operations and Maintenance - Orion
The Gateway, Provider Directory, and PKI infrastructure will go live on October 15, 2012. The additional services will go live in December 2012.
We believe that our System Integration vendor, Orion, has substantial US and international experience with Public HIE implementations. Their centralized cloud hosted gateways keep costs low and agility high. For those clinicians using non-certified or non-Direct compliant EHRs, Orion will provide and manage a low cost appliance in office settings to enable participation in bidirectional data sharing. Initiate has rich experience with directories and query interfaces to directories, both patient and provider. Symantec (which acquired Verisign) has thousands of public key infrastructure customers. The combination of Orion, Initiate and Symantec seems highly credible to us.
We have completed an analysis of every EHR deployed in Massachusetts and discovered that we can connect 80% of our stakeholders (including Long Term Care and Behavioral Health) by creating HIE interfaces for:
•Meditech
•LMR (Self developed at Partners Healthcare)
•Cerner
•Allscripts
•eClinicalWorks
•GE
•WebOMR (Self developed at Beth Israel Deaconess)
•Siemens
•Epic
•NextGen
•athenahealth
•Quest Care360
•E-MDs
•Point Click Care
•Netsmart Technologies
•UNI/CARE Systems
The Massachusetts eHealth Institute (MeHI) Last Mile Management Office will hire a System Integrator to manage interface development and the selection of implementation optimizing organizations to manage interface implementation and training.
With capital funding in place, a sustainable operating budget with public/private contributions, and strong vendors, we are confident the Massachusetts Statewide HIE will leverage Federal Standards to connect payers, providers, and patients in empowering ways. I'll write many additional posts describing the technology and policy decisions we make along the path to our October go live.
Truly the perfect storm for innovation.
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