Making a Difference

Although I usually reserve Thursday for personal blogs, Father's Day was a time for reflection that enabled me to put aside the endless emails, operational tribulations, and budget season stresses to think about what really matters.

In my 51 years, 2013 marked the first time I've had no father with me on Father's Day.  For the first time, I've taken on the mantle of "alpha" father for the family.

I celebrated Father's day with my wife, daughter and her partner David, enjoying a Japanese lunch and helping them rewire the kitchen in their new apartment.   They rent one of 4 units in a 1910-era shingled house in Medford.   We braved the dungeon-like basement to find the old breaker box and located the power controls for the kitchen.    I taught them how a GFCI receptacle is wired, carefully isolating the Load and Line sides, the hot wire, the common wire, and the ground.    We then built new kitchen shelving for her pots and pans.    It was a perfect Father's Day, serving those around me and making my daughter's life easier.

I called my mother, as I have done every day since my father's death, to check on her progress.  She's gardening, taking daily walks, and keeping her brain busy with numerous cultural and social activities.

So, what part of this inspired me to think about what really matters?

Will my tombstone read

"He balanced his budget 20 years in a row"
"He addressed all regulatory requirements for over 2 decades"
"He completed all his annual operating plan goals and more"

Unlikely.

If in some small way, I empower my daughter to fledge from the nest, taking responsibility for running a household and finding her own way in the world, I will have created a legacy that could last for a century.

If in some small way, I enable my mother to maintain her wellness, learn new technologies, and experience a rich "act two" after my father's death, I will have made a real impact on her life.

Both are examples of making a difference.

As I look at my weekly calendar, about half my waking hours are spent on operations, a quarter on planning the future, and quarter in service to my family and community.

It's the last quarter, when I give my time, that has the greatest chance of impacting the long term future of those around me, accelerating the progress of the next generation, and catalyzing good outcomes in the world.

While balancing a budget is a must do, it's quickly forgotten.   You're only as good as your last budget cycle or your last successful project.

However, if your family, your colleagues, and your students feel inspired by something you've said, a situation you've created, or a barrier you've broken down, then you've created a memory that can last a lifetime.

So next time your equanimity is challenged by a person, situation, or event in your job, remember that such issues are transient.    Focus your emotional energy on that which really matters and you'll make a difference.   That's the pot of gold at the end of my rainbow (photo taken at Unity Farm a few hours ago)

Building Unity Farm - Little Glamour, Lots of Laundry

My wife and I owned and operated a small winery on the Marin/Sonoma border in Northern California when we were in our 20's - from 1986-1991.   When I told my colleagues at the time that I ran a winery, they commented on the romance, art, and elegant lifestyle it implied.   It was agriculture.  It was hot, sweaty, and dusty.   You could make a small fortune in the wine business - as long as you started with a large fortune.   I relished the experience, but it was not elegant.

In many ways, running a small farm is the same.   The notion of a hobby farm or gentleman's farm sounds so Thoreau.    In reality, it's a lot of laundry.

Every morning before leaving the farm at 6:45am for the commute to Boston, I feed the animals, fill their water buckets, and clean stalls.   I make sure that no predators visited overnight, that crops were watered by irrigation systems, and that compost is moist but not too moist.

The picture above illustrates what it's like to manage the manure of 50 animals - that's a 16x16x3 foot compost pile.

Farm work is extremely satisfying and is an essential part of maintaining my equanimity.  Shoveling manure, hauling hay, and splitting wood are very Zen.

The difference between farm life  and suburban residential life is the scale.

Have you ever mulched your garden?    The picture below is the mulch pile for the trails of Unity Farm.  I run the dogs on the trails every night and they enjoy climbing the wood chip pile before it becomes trail mulch.

Weekends are filled with joyful work - every moment from 6am to 6pm is constant movement.

By the end of the day, I'm covered with hay, dirt, manure, forest debris, and animal hair.

The clothing I wear on the farm is the same tough climbing gear from Arcteryx that I've worn for years as an alpinist.   Not only does it stand up to the rigors of farm work, it also lasts through the repeated washings (at least two per weekend) needed to return the fabric to its baseline state.

The scale of Unity Farm as described in our LLC filing and Chapter 61A application (agricultural status) is

"Unity Farm raises alpaca for fiber for production to spun yarns.
        This can include milling of blankets or other objects beyond yarn.
         Also possible is the sale of cria (baby alpaca), as a result of our breeding plan

Fruits, eggs, honey, and gourmet mushrooms are planned components of the farmstand.
          Possible addition of other seasonal crops from the hoophouse
          Local flowers possible
       
Considerations include pasturage, cropland, location of farmstand, and web sales. Ecotourism and Northeast Organic Farming Associaton certification are to be considered."

We're not an agribusiness, we're a local community resource.    We may be the size of a gentleman's farm  but we're not very gentlemanly.   Little glamour, lots of laundry.   If you want to try it yourself, here's some of the best advice I've ever found.

The Healthcare Information Technology Maturity Model

Previously I wrote about Frameworks for IT Management, including the Capability Maturity Model.

Recently, I collaborated with Intel Corporation, HIMSS Analytics and Innovation Value Institute to evaluate the BIDMC IS organization and better understand our strengths and weaknesses.  

Here's an overview of the process

The report evaluated our ability to manage IT like business, manage the budget, manage our capabilities, and manage our portfolio of projects to optimize business value.

Given the volatility and uncertainty in healthcare and technology, it's important to continuously evaluate priorities, opportunities, and threats.    Some days can feel like ADHD.    Some weeks can feel overwhelming.

As a manager, I need to focus more on the areas that need improvement and less on the areas that are good enough.

Benchmarking exercises to discover where you have high and low maturity compared with other organizations are useful.   Sometimes you do not know what you do not know.

In my career, I've moved very fast on issues such as web-enabling applications, hosting in the cloud, and securely sharing data.   I've moved slower on areas of disaster recovery, social media policy, and some aspects of formal documentation.

The HIT Maturity Model was a useful exercise that helped me focus my plans for the next year.

The great thing about being an IT leader is that our work will never be done.   Frameworks for IT management and benchmarking tools help us with the journey.

A Social Security Interoperability Update

A few years ago, I wrote about the groundbreaking Social Security Administration automated disability adjudication system, Megahit.

Patient sign a consent in their local social security office and that consent is digitally sent to BIDMC.   The appropriate medical information needed to support disability claims is automatically assembled and cryptographically transmitted to SSA.

Here are a few stats on the SSA/BIDMC partnership.  Since our 2008 go live, SSA has received 6,916 medical records from BIDMC (and 71,500 from hospitals and providers across the country) .  Of those, 663 BIDMC medical records  (and 7,624 from hospitals and providers across the country) triggered one or more of SSA’s business rules, which resulted in targeted decision support for SSA adjudicators, speeding the disability determinations process. Thus far in FY 2013, about 6 percent of disability cases in Massachusetts were decided within 48 hours. SSA has seen significant improvements in the disability determination process using health information exchange to obtain medical records.  In FY 2012, they lowered disability case processing time by approximately 23 percent for those cases containing medical records obtained through health information exchange.
 
When SSA receives electronic health records from a partner organization, such as BIDMC, there are many benefits:
faster disability determinations are possible for claimants,
quicker access to monthly cash benefits are possible, and
earlier access to medical insurance coverage is obtained.

Healthcare providers benefit from increased patient satisfaction rates,
reduced uncompensated care, reduced administrative costs associated with medical record requests, and
automated fiscal payments from SSA.

Here is the link to SSA’s health IT website, which provides additional information on the initiative.   It's been a very successful health information exchange project.

Building Unity Farm - A Day in June

And what is so rare as a day in June?
   Then, if ever, come perfect days;
Then Heaven tries the earth if it be in tune,
   And over it softly her warm ear lays
JAMES RUSSELL LOWELL

Unity Farm is at the peak of growth now, fueled by warm days, cool nights, and Spring rains.

The Bluebird Meadow, pictured above, is filled with tall grasses and wildflowers.   The three bluebird nest boxes I built are filled with growing chicks.

The Orchard, planted just a few weeks ago, is blooming and filled with its first growth of orchard grass, timothy hay, and meadow mix.

Our 8 bee hives are filling with honey, a mixture of pollen/nectar gathered from the orchard, viburnum, and wildflowers.

Adult rabbits are running thoughout the forest and their babies are hiding in our Cotoneaster brambles

We have an active fox den on the property, midway up the drumlin in the deepest part of our forest, in well drained soil, about 100 feet from our upper wetland.   My guess is that it was an old groundhog den, since the first three feet of the main entrance were recently enlarged and dug into a tall oval shape that enables the fox to bolt out at a full gallop.    Every night when I run our Great Pyrenees through the forest they want to leave the Woodland Path  (Unity Farm has 4 paths - Woodland, Orchard, Marsh, and the Old Cart path) to explore the den.   The alluring scent of fox urine is irresistible .   The one downside to having an active fox den on the property is that one of our Guinea fowl disappeared on Tuesday night.   I believe she was laying an egg in the forest (Guineas are terrible parents) and she was grabbed by a fox before she could fly away.   I found a broken egg, a path of feathers, and no Guinea.    All the Guineas come home to roost at dusk, but on Tuesday night, only 17 of our 18 Guineas returned.

The Unity woodland is covered with ferns of all kinds - cinnamon, hay scented, and sensitive ferns.   I used my scythe to recut the trails through the sea of green underbrush.   I've also had the seasonal joy of removing poison ivy from the trails by pulling it out at the roots.

The new alpaca had their first vet visit this week and we've updated their rabies and CDT (clostridium perfringens types C and D and tetanus) vaccinations.   We checked their ears, eyes, and teeth.   All were perfect.    Since they lived with goats, we checked them for parasitic infections by gathering fecal samples.   Sometimes people wonder how I've learned farming skills.   How do you master alpaca rectal exams?  Just do it!

The most amusing part of the vet visit was checking each new alpaca for the RFID chip implants that are used to positively identify them if a fence is breached and they wander off.    The vet scanned Tahoe, our young male gelding alpaca and could not find his chip.   Just to check the equipment, the vet successfully scanned me, since she had read about my experience as one of the first humans to have implanted RFID identity and medical records technology.

The weekend ahead will be filled with mushroom log inoculation,  adding woodchips to trails, and clearing some of the fallen poplar on the Orchard trail.    There's nothing like a Spring weekend of farm chores to refresh the body, mind and soul.

Presenting the Security Plan to the Board

Today I presented our multi-year information security plan to the BIDMC Board Committee on Compliance, Audit and Risk.  

Here is the presentation I used.

Following our February external review of security policies and technologies, we developed a planning process, and a complete multi-year plan with timelines, budgets, and staffing requirements.

The plan contains 14 work streams, each of which has several components.   Here's a sample work stream planning document illustrating the goals, metrics, timing, and costs.

They key point I emphasized to the Board is that this security work is not just to satisfy federal and state regulatory requirements.   There are many tangible benefits of the work ahead including adoption of the NIST 800 framework, which formalizes our approach to risk management and priority setting.    We'll tightly manage user roles (access by job role rather than person),  devices allowed on the network, and remote access methods/rights.

All of this improvement does have a capital implementation cost and an operating maintenance cost, since we will be adding several new applications that require 24x7 support.

Although I did provide a detailed, phased project plan for each of the work streams, there is one planning task to do.  

Each of the components in the 14 work streams has an associated priority, risk, and cost.   Management at BIDMC will select a collection of projects to begin immediately which we believe will offer the greatest benefit, can be widely adopted by the organization and are affordable.   We will refine our FTE, capital budget, and operating budget requests once we constrain the scope of work to that collection of projects.

We'll ask the original external security reviewers, our multi-stakeholder working group, and the management committee on audit, risk and compliance to offer feedback on the go forward scope.

In many ways, BIDMC tries to be a leader in application and infrastructure innovation.   In the world of security, since risks evolve so rapidly and the future is hard to predict, we have to set scope carefully so that we're good enough - neither over or under implementing appropriate controls,  acquiring the right amount of technology, and hiring the right spectrum of staff.

Massachusetts HIE Update

Yesterday, the HIT Council met to review Massachusetts Healthcare IT progress.

Here is the presentation we used.

The meeting began with a presentation from Holyoke Medical Center, describing an ideal subnetwork - a local HIE that meets the needs of local stakeholders while also connecting to the state HIE, enabling any authorized stakeholder in the Commonwealth to send and receive summaries to/from the Holyoke medical community.

Next, I gave an update on BIDMC's progress.   BIDMC is now live sending immunization transactions to the Department of Public Health over the state HIE.  We're also sending 4000 transactions per day to the quality data center at the Massachusetts eHealth Collaborative.  Today we go live with Network Health for transition of care exchange and in the upcoming weeks we'll go live with Partners healthcare for encounter summary exchange.

Next, we reviewed HISP to HISP trust fabric approaches and consent issues.   For HISP to HISP exchange we agreed that we need both authentication (who you are) and authorization (what you can do).   Although certificate trust bundles like those offered from DirectTrust.org can address federated authentication issues, we'll likely implement authorization within the state HIE as we move from "push" models to "pull" which enable authorized users to retrieve records on demand.  

Massachusetts is an opt-in consent state and we reviewed recommendations for consent processes and language.   Our current recommendation is for HIE participants to obtain opt in consent during the general consent for care signing process and to specifically enumerate the state HIE as a means to share data in the notice of privacy practices.

We reviewed the FY14 plans for the Massachusetts eHealth Institute, the organizations in Massachusetts that accelerates EHR adoption and assists with connecting the "last mile" of provider practices to the HIE.

Finally we reviewed our plans for creating a statewide master patient index, record locator service, and the supporting web services to enable query/response ("pull") health information exchange.  We're on track for an early 2014 go live and all funding is in place.

A great meeting.