The effort to keep the chickens/ducks/guinea fowl safe from the hawks has had its own complications. We originally built the coop (10x16) and pen (10x20) to hold less than 50 birds. Although it�s easy to limit population growth of chickens and ducks (collect the eggs), the guineas lay eggs in hidden forest nests. Our 25 guineas became 70 guineas over the Summer. The coop today has 64 guineas and 11 chickens - 75 birds in close proximity. Normally they roost from dusk to dawn and are running around the farm during daylight hours. By limiting them to the coop during hawk hunting hours, they have less free outdoor time. The consequences are that they have increased proximity and less fresh air movement.
Chocobo, one of our Buff Orpington chickens, is low on the pecking order. This week, while confined, she was pecked by other birds and had mild bleeding of her comb. We cleaned her up, applied Vetericyn (a spray on antibiotic), and isolated her into the mini-coops we use for raising young birds. She�s healed nicely.
Snow, one of our Brahma chickens, developed an upper respiratory infection and began sneezing violently. We�ve done our best to keep the coop open on cloudy days. We�ve dug out all the bushes (buried under 7 feet of ice) that the poultry uses to hide from hawks. Given that Boston just broke all historic winter records, that�s been an ongoing battle. Snow the chicken is doing well now that she has more outside time.
I�ve tried very hard to minimize travel this year, but I was asked to join an important strategic planning session at a foundation in California, support one of our industry partners by giving a keynote in Dubai, and chair the Standards Committee in Washington. Kathy has had to keep the farm running during my time away. The dogs miss me and we tend to defer maintenance tasks and the more physical projects until my return. Balancing my various work tasks, my farm tasks and travel makes me want to use Skype as much as possible, minimizing travel time so that I can serve all the organizations, people, and creatures in my life instead of sit in airports.
As a farmer, my role is maximize the life quality of every creature on the farm. As a CIO, my role is to make a difference with my staff, my country, and the world. In 2014, we acquired all the technologies necessary to maximize farming efficiency, enabling me to use my nights and weekends most wisely. As we ramp up production and scale, we may need to bring on some part time help to support Kathy when my job responsibilities fill the 24 hour day.
Our Spring planting is now done, both hoop house seed planting and indoor seedling germination. The BIDMC COO asked why my fingertips are cracked. My upper extremities are now farmer�s hands and not surgeon�s hands.
I look forward to the thaw of the next few weeks and exciting projects we have planned for late spring including new mushroom production, tree planting, fence mending, wiring the cider house to support the move from hand cranked tools to powered tools, and replacing the 30 year old farm driveway.
In our modern era, each of us will have 5 or more jobs. My heart leads me to farming but my brain drives me to make a difference on as large a scale as possible. For many years to come, I will shovel manure on nights and weekends while �fertilizing� ideas in my technology day jobs.
Kamis, 19 Maret 2015
Rabu, 18 Maret 2015
The March HIT Standards Committee
The March 2015 HIT Standards Committee was one of the most impactful meetings we have ever had. No, it was not the release of Meaningful Use Stage 3 or the certification rule. It was the creation of a framework that will guide all of our work for the next several years - everything we need for a re-charted standards harmonization convening body as well as a detailed interoperability roadmap, complementing the 10 year general plan developed by ONC. Thanks to Arien Malec for yeoman�s work in both areas.
We started the day with an overview of current security risk presented by Ron Ross, National Institute of Standards and Technology (NIST). Admittedly I missed that presentation. Although my flight from Dubai to Washington was early, Metro was shutdown due to an equipment failure at the Rosslyn station. I�m told it was a sobering overview of the increased threats we all are facing.
Next, Dawn Heisey-Grove provided an overview of progress on the most difficult aspects of Meaningful Use Stage 2 - transitions of care, patient/family engagement, electronic medication administration records, and public health data submission. Progress is being made in all areas.
Evelyn Gallego-Haag presented a progress update on the Electronic Long Term Support Services (eLTSS). Committee members offered two kinds of advice. Care plan development and exchange maybe an �app� and not a standard. If a standard is needed, existing standards should be leveraged instead of creating a new approach.
Stan Huff and Arien Malec presented a work of art - the Standards and Interoperability (S&I) Initiative Task Force Recommendations . Their guiding principles were welcomed by all - ONC does need a convening function for aligning SDO work and national priorities, but standards making should be left to SDOs. Prioritization must be multi-stakeholder and not dominated by any one entity. We must align demand with the reality of the supply of mature standards. The S&I Framework can be re-chartered with these new guidelines and will represent the third generation of standards harmonization efforts, building on the lessons learned from HITSP and the existing S&I efforts.
Next we heard a series of reports from workgroups reviewing the ONC Interoperability roadmap.
Liz Johnson and Cris Ross provided the perspective of the Implementation, Certification, and Testing workgroup. The most important aspect of the presentation was the cleanup of CCDA, reducing optionality. CCDA R2 will be much easier to parse than CCDA R1.
Andy Wiesenthal and Rich Elmore summarized the work of the Content Standards workgroup.
Jamie Ferguson presented the work of the Semantic Standards workgroup.
Dixie Baker and Lisa Gallager presented the recommendations of the Transport and Security Standards workgroup.
Next we heard the most important presentation thus far in 2015, Arien Malec and David McCallie presenting the work of the Architecture, Services, and APIs workgroup. The key recommendation was aligning healthcare standards with the approach that has been used by the groups creating internet standards - bring running code and embrace phased improvement in real world implementations. They elegantly categorized the work to be done on existing standards while transitioning to a broad implementation of future standards - FHIR, OAuth2, and REST. The entire Standards Committee applauded the effort which contains enough detail to implement now. It provides all the interoperability planning detail that Congress has been asking for. We declared the effort, a yellow brick road leading to standards nirvana, with courage, wisdom and heart (ending with finished FHIR specifications from the land of Oz)
The day ended with a roadmap for Quality Measurement standards presented by Julia Skapik.
After the Standards Committee meeting, many joined the Argonauts steering committee meeting to hear and updated on the accelerated effort to bring FHIR/OAuth2/RESTful application program interfaces to most mainstream EHRs. It�s on track through the diligent efforts of many dedicated participants.
Today was a banner day for healthcare interoperability. In the next days to weeks as Meaningful Use Stage 3 NPRMs are released, we all hope that the frameworks presented today can be applied to the policy goals of emerging regulations.
We started the day with an overview of current security risk presented by Ron Ross, National Institute of Standards and Technology (NIST). Admittedly I missed that presentation. Although my flight from Dubai to Washington was early, Metro was shutdown due to an equipment failure at the Rosslyn station. I�m told it was a sobering overview of the increased threats we all are facing.
Next, Dawn Heisey-Grove provided an overview of progress on the most difficult aspects of Meaningful Use Stage 2 - transitions of care, patient/family engagement, electronic medication administration records, and public health data submission. Progress is being made in all areas.
Evelyn Gallego-Haag presented a progress update on the Electronic Long Term Support Services (eLTSS). Committee members offered two kinds of advice. Care plan development and exchange maybe an �app� and not a standard. If a standard is needed, existing standards should be leveraged instead of creating a new approach.
Stan Huff and Arien Malec presented a work of art - the Standards and Interoperability (S&I) Initiative Task Force Recommendations . Their guiding principles were welcomed by all - ONC does need a convening function for aligning SDO work and national priorities, but standards making should be left to SDOs. Prioritization must be multi-stakeholder and not dominated by any one entity. We must align demand with the reality of the supply of mature standards. The S&I Framework can be re-chartered with these new guidelines and will represent the third generation of standards harmonization efforts, building on the lessons learned from HITSP and the existing S&I efforts.
Next we heard a series of reports from workgroups reviewing the ONC Interoperability roadmap.
Liz Johnson and Cris Ross provided the perspective of the Implementation, Certification, and Testing workgroup. The most important aspect of the presentation was the cleanup of CCDA, reducing optionality. CCDA R2 will be much easier to parse than CCDA R1.
Andy Wiesenthal and Rich Elmore summarized the work of the Content Standards workgroup.
Jamie Ferguson presented the work of the Semantic Standards workgroup.
Dixie Baker and Lisa Gallager presented the recommendations of the Transport and Security Standards workgroup.
Next we heard the most important presentation thus far in 2015, Arien Malec and David McCallie presenting the work of the Architecture, Services, and APIs workgroup. The key recommendation was aligning healthcare standards with the approach that has been used by the groups creating internet standards - bring running code and embrace phased improvement in real world implementations. They elegantly categorized the work to be done on existing standards while transitioning to a broad implementation of future standards - FHIR, OAuth2, and REST. The entire Standards Committee applauded the effort which contains enough detail to implement now. It provides all the interoperability planning detail that Congress has been asking for. We declared the effort, a yellow brick road leading to standards nirvana, with courage, wisdom and heart (ending with finished FHIR specifications from the land of Oz)
The day ended with a roadmap for Quality Measurement standards presented by Julia Skapik.
After the Standards Committee meeting, many joined the Argonauts steering committee meeting to hear and updated on the accelerated effort to bring FHIR/OAuth2/RESTful application program interfaces to most mainstream EHRs. It�s on track through the diligent efforts of many dedicated participants.
Today was a banner day for healthcare interoperability. In the next days to weeks as Meaningful Use Stage 3 NPRMs are released, we all hope that the frameworks presented today can be applied to the policy goals of emerging regulations.
Kamis, 12 Maret 2015
Unity Farm Journal - Second Week of March 2015
The thaw has begun. This week, for the first time in 2015, we�ll have daytime temperatures above freezing. The 8 foot snowbanks are starting to recede, although the Great Pyrenees can still look down on the 6 foot fences.
As the snow melts, creatures are becoming more active. Birds are gathering hay for nesting (I cleaned out all the birdhouses in February), skunks have wakened from the dormant state and are wandering around the farm (I can smell them), and the fisher cats are prowling around the barn at night looking for prey. The dogs have been barking for hours every night, keeping the barnyard animals safe from predators. This morning, I noticed fisher cat tracks around the entire poultry area. Everyone is safe and healthy.
It�s Spring planting time, and last weekend was spent creating our transplant stock in anticipation of hoop house planing over the next 2 months. Although I directly seed many of the vegetables into raised beds, the heat loving plants are germinated indoors. This year that includes
Cucumbers - 12 large pots
Peppers - 24 small pots
Broccoli - 12 small pots
Eggplant - 12 small pots
Zucchini - 4 large pots
Kabocha Pumpkin/Squash- 5 large pots
This weekend, I�ll finish planting the spring greens - 3 different kinds of spinach and 5 different kinds of lettuce.
The Federal Alcohol and Tobacco Tax and Trade Bureau is nearly ready to approve our cider making application as a bonded cider winery. I�ve made 8 different kinds of hard ciders as test batches for personal consumption and once licensed, we can ramp up production. We�ll have 6000 pounds of apples each season in the next few years. I�ve been designing a premium beverage - Halamka�s India Pale Ale with Apple - HIPAA. It builds strong bodies twelve ways and protects your privacy!
I�m off to Dubai on Saturday night to give a keynote and Kathy will be running the farm until Tuesday. I really hope the fast melting snow does not become a fast melting flood in my absence.
As the snow melts, creatures are becoming more active. Birds are gathering hay for nesting (I cleaned out all the birdhouses in February), skunks have wakened from the dormant state and are wandering around the farm (I can smell them), and the fisher cats are prowling around the barn at night looking for prey. The dogs have been barking for hours every night, keeping the barnyard animals safe from predators. This morning, I noticed fisher cat tracks around the entire poultry area. Everyone is safe and healthy.
It�s Spring planting time, and last weekend was spent creating our transplant stock in anticipation of hoop house planing over the next 2 months. Although I directly seed many of the vegetables into raised beds, the heat loving plants are germinated indoors. This year that includes
Cucumbers - 12 large pots
Peppers - 24 small pots
Broccoli - 12 small pots
Eggplant - 12 small pots
Zucchini - 4 large pots
Kabocha Pumpkin/Squash- 5 large pots
This weekend, I�ll finish planting the spring greens - 3 different kinds of spinach and 5 different kinds of lettuce.
The Federal Alcohol and Tobacco Tax and Trade Bureau is nearly ready to approve our cider making application as a bonded cider winery. I�ve made 8 different kinds of hard ciders as test batches for personal consumption and once licensed, we can ramp up production. We�ll have 6000 pounds of apples each season in the next few years. I�ve been designing a premium beverage - Halamka�s India Pale Ale with Apple - HIPAA. It builds strong bodies twelve ways and protects your privacy!
I�m off to Dubai on Saturday night to give a keynote and Kathy will be running the farm until Tuesday. I really hope the fast melting snow does not become a fast melting flood in my absence.
Rabu, 11 Maret 2015
Outcomes as a Service
On Monday, I wrote a brief op-ed for the Wall Street Journal about the reality of cloud computing. You can read the full article here.
I classified cloud computing in three different concepts
Infrastructure as a Service (IaaS) - your applications outsourced to someone else�s servers.
Platform as a service (PaaS) - a set of foundational software tools for building your applications on someone else�s servers and software.
Software as a service (SaaS) - a set of applications, created and operated by a third party which does not require installation of local hardware or software. You subscribe to comprehensive remotely hosted functionality.
I concluded that outsourcing your mess to someone else to host is not cloud computing.
Instead IT leaders should focus on a variation on SaaS, which I called �Outcomes as a Service�. Software and hardware are one component, but the combination of business processes, people, and technology work in concert to achieve a desired result. Payment is made when that result is delivered. Examples are the athenahealth EHR/practice management/billing service, the Cornerstone Learning Management System service, and the Workday financial applications.
CIOs throughout the country are struggling with IT scalability - the capacity to meet the automation needs of the business given regulatory demands (ICD10, Meaningful Use, HIPAA Omnibus Rule, Affordable Care Act), limited time, and relatively fixed resources.
Often IT is asked to delivered unplanned work, within current budgets, and without disrupting current projects in process. It�s like asking 9 women to gestate a baby in 1 month.
One of the few ways that a CIO can stay sane (other than resource leveling and governance, which I discussed last week ) is to have the flex capacity to deliver outcomes for a price.
The business can be told that an Outcomes as a Service provider exists and the business can have as much of that service as they can pay for. The CIO enables the service but does not provision it or operate it.
As I�ve written about before, the CIO�s role is increasingly diverse. I�ve watched CIOs crumble under the strain the job, which often seems overwhelming - demand exceeding supply, constant change with complete reliability, and perfect security with ubiquitous access.
Relying increasingly on Outcomes as a Service vendors, freeing up the CIO to spend more time with business owners and governance activities, is likely one of the most successful tactics to enhance CIO job retention and satisfaction.
I classified cloud computing in three different concepts
Infrastructure as a Service (IaaS) - your applications outsourced to someone else�s servers.
Platform as a service (PaaS) - a set of foundational software tools for building your applications on someone else�s servers and software.
Software as a service (SaaS) - a set of applications, created and operated by a third party which does not require installation of local hardware or software. You subscribe to comprehensive remotely hosted functionality.
I concluded that outsourcing your mess to someone else to host is not cloud computing.
Instead IT leaders should focus on a variation on SaaS, which I called �Outcomes as a Service�. Software and hardware are one component, but the combination of business processes, people, and technology work in concert to achieve a desired result. Payment is made when that result is delivered. Examples are the athenahealth EHR/practice management/billing service, the Cornerstone Learning Management System service, and the Workday financial applications.
CIOs throughout the country are struggling with IT scalability - the capacity to meet the automation needs of the business given regulatory demands (ICD10, Meaningful Use, HIPAA Omnibus Rule, Affordable Care Act), limited time, and relatively fixed resources.
Often IT is asked to delivered unplanned work, within current budgets, and without disrupting current projects in process. It�s like asking 9 women to gestate a baby in 1 month.
One of the few ways that a CIO can stay sane (other than resource leveling and governance, which I discussed last week ) is to have the flex capacity to deliver outcomes for a price.
The business can be told that an Outcomes as a Service provider exists and the business can have as much of that service as they can pay for. The CIO enables the service but does not provision it or operate it.
As I�ve written about before, the CIO�s role is increasingly diverse. I�ve watched CIOs crumble under the strain the job, which often seems overwhelming - demand exceeding supply, constant change with complete reliability, and perfect security with ubiquitous access.
Relying increasingly on Outcomes as a Service vendors, freeing up the CIO to spend more time with business owners and governance activities, is likely one of the most successful tactics to enhance CIO job retention and satisfaction.
Kamis, 05 Maret 2015
Unity Farm Journal - First Week of March 2015
The snow, ice and sleet continues. February was the snowiest month we have ever had in Boston had with 64.8 inches. It was also the second-coldest February on record.
I�ve attacked the endless frozen tundra of Unity Farm with the Terex front loader,an ice chipper, and a stainless steel SnowEx salt/sand spreader. I try to use Calcium Chloride or a Magnesium Chloride mix which is safer for the plants and animals. We�ve gone through 250 pounds of salt and 250 pounds of sand every weekend in 2015. The March weather thus far has varied between a high of 43 and a low of zero F. The snow melts a bit, then refreezes. It�s like chunky concrete at this point. The industrial sized snowblower attachment for the Terex arrives this weekend, but I�m not sure a snowblower can help with the glaciers that now surround the farm. Next year, I�ll move the powder before it becomes a solid.
The bees continue to struggle with the record low temperatures and precipitation. We started the winter with 11 living hives and now we have 7. In the Spring, we�ll refill a few of the hives by moving a portion of the bees and queens from existing hives to empty hives - a kind of forced swarming. The queen-less hives will make new queens. We�ve also ordered some �mini-hives� of overwintered Russian bees from Western Massachusetts. These small hives are called a �nucleus� or �nuc�. I�m sure that folks overhearing our conversation were worried when my wife announced that she purchased two Russian Nukes.
Last week, I wrote about my conversation with the hawk that visited the chicken coop and killed a guinea. The hawk did not return, but unfortunately, it told two even larger friends about the coop. Kathy noticed an enormous hawk sitting on the coop roof one morning. Last weekend, I found the dismembered body of Belle, the duck who we nursed back to health after a serious eye infection. The hawks broke her next and ate about half of her upper body. I buried her under 6 feet of snow, since I cannot dig the frozen ground.
We�ve changed the daily schedule for all the poultry at Unity Farm. During the lean times for the predators, when all natural food sources are covered with snow, we�ll keep all the coops and pens locked until 4pm each day, since the peak of the hunting seems to occur between 9am-3pm. Once the snow melts and the trees begin to leaf out, we�ll restore the usual daylight freedom that the poultry have always enjoyed. Our task as farmers is to maximize the quality of life of the creatures at Unity farm, while also keeping them alive!
We�ve ordered all our seeds for 2015, so hopefully I can plant peas next week and begin to prepare the overwintered raised beds for the Spring growing season ahead.
I�ve attacked the endless frozen tundra of Unity Farm with the Terex front loader,an ice chipper, and a stainless steel SnowEx salt/sand spreader. I try to use Calcium Chloride or a Magnesium Chloride mix which is safer for the plants and animals. We�ve gone through 250 pounds of salt and 250 pounds of sand every weekend in 2015. The March weather thus far has varied between a high of 43 and a low of zero F. The snow melts a bit, then refreezes. It�s like chunky concrete at this point. The industrial sized snowblower attachment for the Terex arrives this weekend, but I�m not sure a snowblower can help with the glaciers that now surround the farm. Next year, I�ll move the powder before it becomes a solid.
The bees continue to struggle with the record low temperatures and precipitation. We started the winter with 11 living hives and now we have 7. In the Spring, we�ll refill a few of the hives by moving a portion of the bees and queens from existing hives to empty hives - a kind of forced swarming. The queen-less hives will make new queens. We�ve also ordered some �mini-hives� of overwintered Russian bees from Western Massachusetts. These small hives are called a �nucleus� or �nuc�. I�m sure that folks overhearing our conversation were worried when my wife announced that she purchased two Russian Nukes.
Last week, I wrote about my conversation with the hawk that visited the chicken coop and killed a guinea. The hawk did not return, but unfortunately, it told two even larger friends about the coop. Kathy noticed an enormous hawk sitting on the coop roof one morning. Last weekend, I found the dismembered body of Belle, the duck who we nursed back to health after a serious eye infection. The hawks broke her next and ate about half of her upper body. I buried her under 6 feet of snow, since I cannot dig the frozen ground.
We�ve changed the daily schedule for all the poultry at Unity Farm. During the lean times for the predators, when all natural food sources are covered with snow, we�ll keep all the coops and pens locked until 4pm each day, since the peak of the hunting seems to occur between 9am-3pm. Once the snow melts and the trees begin to leaf out, we�ll restore the usual daylight freedom that the poultry have always enjoyed. Our task as farmers is to maximize the quality of life of the creatures at Unity farm, while also keeping them alive!
We�ve ordered all our seeds for 2015, so hopefully I can plant peas next week and begin to prepare the overwintered raised beds for the Spring growing season ahead.
Rabu, 04 Maret 2015
Resource Leveling
In an era when demand for IT services always exceeds supply, it�s important to triage incoming requests and allocate existing resources to completing the highest priority projects in the shortest time.
Time, scope, and resources are the only three levers available to a CIO. Scope can be set by governance and steering committees, but time and resources often fall to the CIO to allocate.
I have long used the concept of resource leveling, which sets project start and end dates based on available resources.
This year, I�m bringing resource leveling dashboards to all my governance committees so that as new projects are requested, it is clear which projects will be delayed (or not started) by the insertion of new scope.
Expectations of service delivery in 2015 are compounded by the instant gratification of �there�s an app for that, how hard can it be�. Cycle times of 18 months are no longer acceptable. I can reduce the scope of projects by moving as many applications to Software as a Service subscriptions, relying on the scalability of vendors rather than the relatively fixed pool of IT staff, but for the many tasks still only available through internal building, I need to expand the resource leveling accountability beyond the office of the CIO to the business owners, so that the start/end times for projects are not �my� plan but �our� plan.
When the stakeholders have visibility into the allocation of resources, understanding the trade offs that must be made as new regulatory requests, urgent incident response, and unplanned strategic projects are added to the plate, hopefully there will better alignment between expectations and service delivery.
As the entire healthcare industry experiences accelerating change, and pressure to perform in a resource constrained environment increases, it is easy to single out IT as the rate limiting step to success. Over the next 6 months, I hope to turn that conversation around as stakeholders have a role in resource leveling and can broadly communicate the decisions made collectively, providing the greatest IT good for the greatest number of stakeholders in the shortest time.
Time, scope, and resources are the only three levers available to a CIO. Scope can be set by governance and steering committees, but time and resources often fall to the CIO to allocate.
I have long used the concept of resource leveling, which sets project start and end dates based on available resources.
This year, I�m bringing resource leveling dashboards to all my governance committees so that as new projects are requested, it is clear which projects will be delayed (or not started) by the insertion of new scope.
Expectations of service delivery in 2015 are compounded by the instant gratification of �there�s an app for that, how hard can it be�. Cycle times of 18 months are no longer acceptable. I can reduce the scope of projects by moving as many applications to Software as a Service subscriptions, relying on the scalability of vendors rather than the relatively fixed pool of IT staff, but for the many tasks still only available through internal building, I need to expand the resource leveling accountability beyond the office of the CIO to the business owners, so that the start/end times for projects are not �my� plan but �our� plan.
When the stakeholders have visibility into the allocation of resources, understanding the trade offs that must be made as new regulatory requests, urgent incident response, and unplanned strategic projects are added to the plate, hopefully there will better alignment between expectations and service delivery.
As the entire healthcare industry experiences accelerating change, and pressure to perform in a resource constrained environment increases, it is easy to single out IT as the rate limiting step to success. Over the next 6 months, I hope to turn that conversation around as stakeholders have a role in resource leveling and can broadly communicate the decisions made collectively, providing the greatest IT good for the greatest number of stakeholders in the shortest time.
Jumat, 27 Februari 2015
What is the Optimal Future Role for ONC?
As Meaningful Use winds down and incentive dollars are fully spent, what is the optimal role for ONC going forward?
Some pundits have suggested that ONC step aside and return all aspects of HIT policy and technology to the private sector. Others have suggested top down command and control of HIT including centralized governance to ensure interoperability.
Harmony is when all parties feel equally good about the path forward. Compromise is when everyone leaves the table equally unhappy. Here�s my view about the future of ONC that includes points from both sides.
The Argonaut initiative is a good exemplar of the private sector working to enhance interoperability in response to the market demands of accountable care organizations, which depend on data to succeed in a risk contracting world. There is clearly a role for the private sector to lead innovation and standards adoption, and this role will continue to grow as demand for richer interoperability increases and technology matures. However, even the best innovations require a regulatory and ecosystem context to enable the marketplace to blossom. The health care sector is the most fragmented industry in our complicated economy, both on the demand side (patients, insurers, employers) and on the supply side (physician practices and hospitals). ONC can be a focal point for the discussion of regulatory barriers to data liquidity, novel workflows, and alignment of incentives.
In Massachusetts, opioid abuse is a critical public health problem. We believe that collecting all opioid prescriptions at a state government level and sharing that data with licensed caregivers is appropriate. Yet, right across the border in New Hampshire, it�s illegal to share such data with government entities. Similar prohibitions exist on sharing immunization data to prevent measles outbreaks or syndromic survellience data to detect Ebola. Extrapolate this problem out to the various combinations of 56 states and territories and it's an interoperability nightmare for patients, providers, and vendors. ONC can provide national frameworks that enable regional variation but can suggest guardrails so that a federated national network of interoperability and functionality is not impeded.
Canada has 35 million people. Sweden has 10 million. Healthcare IT policymaking that takes into account stakeholder opinions in these countries is easier than resolving the difference of 320 million US residents. Someone needs to be a convener to give voice to the myriad stakeholder priorities of a country that glorifies individual freedom. ONC can be such a convener.
The US government is a large player in the health care market, even aside from any oversight role it might play. Medicare and Medicaid are the largest health insurers in the country. The US government has over 20 million employees whose health benefits it covers. The DoD, VA, and Indian Health Services are large providers of care. The number of federal agencies and the many and varied ways that they affect health care delivery and health information technology is hard to quantify. There is no single front door in the federal government for HIT related strategic planning across agencies. ONC can serve as government agency harmonizer.
Although Accountable Care Organizations now have economic incentives to accelerate interoperability, they do not have specific incentives to focus on healthcare IT usability and the safety of IT tools. We are now at a point where everything that happens in a hospital is somehow tied to information technology. ONC can provide funding to study issues that lack a specific private sector market force, just as NHTSA and NTSB do with auto and airline safety.
Finally, although there are many federal and state laws that protect privacy and security, it is challenging to know how to measure the security of an EHR. By working with other federal agencies to identify best practices, ONC can foster data integrity and promote respect for patient privacy preferences.
Thus, although the private sector can lead innovation and accelerate standards development, the combination of government, industry and academia is needed to optimize our journey. I recently spoke with a cabinet secretary in the Massachusetts government and the person told me �the Baker Administration does not believe in less regulation or more regulation, it believes in right regulation.� The same can be said of the balance between ONC and the private sector. The list of tasks above seems like the �right regulation� to me.
Some pundits have suggested that ONC step aside and return all aspects of HIT policy and technology to the private sector. Others have suggested top down command and control of HIT including centralized governance to ensure interoperability.
Harmony is when all parties feel equally good about the path forward. Compromise is when everyone leaves the table equally unhappy. Here�s my view about the future of ONC that includes points from both sides.
The Argonaut initiative is a good exemplar of the private sector working to enhance interoperability in response to the market demands of accountable care organizations, which depend on data to succeed in a risk contracting world. There is clearly a role for the private sector to lead innovation and standards adoption, and this role will continue to grow as demand for richer interoperability increases and technology matures. However, even the best innovations require a regulatory and ecosystem context to enable the marketplace to blossom. The health care sector is the most fragmented industry in our complicated economy, both on the demand side (patients, insurers, employers) and on the supply side (physician practices and hospitals). ONC can be a focal point for the discussion of regulatory barriers to data liquidity, novel workflows, and alignment of incentives.
In Massachusetts, opioid abuse is a critical public health problem. We believe that collecting all opioid prescriptions at a state government level and sharing that data with licensed caregivers is appropriate. Yet, right across the border in New Hampshire, it�s illegal to share such data with government entities. Similar prohibitions exist on sharing immunization data to prevent measles outbreaks or syndromic survellience data to detect Ebola. Extrapolate this problem out to the various combinations of 56 states and territories and it's an interoperability nightmare for patients, providers, and vendors. ONC can provide national frameworks that enable regional variation but can suggest guardrails so that a federated national network of interoperability and functionality is not impeded.
Canada has 35 million people. Sweden has 10 million. Healthcare IT policymaking that takes into account stakeholder opinions in these countries is easier than resolving the difference of 320 million US residents. Someone needs to be a convener to give voice to the myriad stakeholder priorities of a country that glorifies individual freedom. ONC can be such a convener.
The US government is a large player in the health care market, even aside from any oversight role it might play. Medicare and Medicaid are the largest health insurers in the country. The US government has over 20 million employees whose health benefits it covers. The DoD, VA, and Indian Health Services are large providers of care. The number of federal agencies and the many and varied ways that they affect health care delivery and health information technology is hard to quantify. There is no single front door in the federal government for HIT related strategic planning across agencies. ONC can serve as government agency harmonizer.
Although Accountable Care Organizations now have economic incentives to accelerate interoperability, they do not have specific incentives to focus on healthcare IT usability and the safety of IT tools. We are now at a point where everything that happens in a hospital is somehow tied to information technology. ONC can provide funding to study issues that lack a specific private sector market force, just as NHTSA and NTSB do with auto and airline safety.
Finally, although there are many federal and state laws that protect privacy and security, it is challenging to know how to measure the security of an EHR. By working with other federal agencies to identify best practices, ONC can foster data integrity and promote respect for patient privacy preferences.
Thus, although the private sector can lead innovation and accelerate standards development, the combination of government, industry and academia is needed to optimize our journey. I recently spoke with a cabinet secretary in the Massachusetts government and the person told me �the Baker Administration does not believe in less regulation or more regulation, it believes in right regulation.� The same can be said of the balance between ONC and the private sector. The list of tasks above seems like the �right regulation� to me.
Kamis, 26 Februari 2015
Unity Farm Journal - 4th week of February 2015
With Spring arriving in 23 days, the farm is beginning the transition from surviving the bitter cold to nesting and reproduction - the Birds and the Bees.
First the Birds. I sent my daughter the picture below and asked her if she could guess what happened?
Over the weekend, I went into the coop to fill the feeders and found a dead guinea surrounded by a pile of feathers.
I looked up and a large red tail hawk was standing on the roost above my head.
I removed all the guineas/chickens and closed the coop door. Not knowing how the bird would respond to my interventions I asked Kathy to supervise me in case I was attacked.
Wearing my kevlar work gloves I gently picked up the bird by its talons and placed it on my arm so I could walk it out of the coop. The bird and I had a conversation for several minutes. I explained that I respected its position at the top of the local food chain, but that Unity Farm could not be a weekly smorgasbord during the lean times of winter. As you can see in the picture, our discussion was intense - direct eye contact and uninterrupted focus. The bird and I walked to the orchard and I encouraged it to fly by gently moving my arm up and down, exercising the raptor�s wings. The bird then flew off, circled the barnyard once, and roosted in a tall old maple snag.
Although I have no desire to take up falconry (it�s not very vegan), I did read about the history, training techniques, and bird personalities involved in the sport. Red tail hawks are known for the equanimity - a very even temperament. They never develop affection for their handlers, but they do develop trust. Given the chickens, ducks and guineas at Unity Farm, we do not want the hawk to visit often.
Next, the Bees.
On Sunday, the temperature rose above freezing for the first time in a month. The bees cannot fly below 40 degrees, and in general, we do not open the hives below 50 degrees. Bees do not excrete in the hive, so they have had to �hold it� for the past 30 freezing days. As soon as the temperature hit 45F, our 100,000 bees began their cleansing flights.
We have not been able to open the hives since January, so we had now idea how the hives were overwintering through -10F temperatures and weekly snowstorms. Every Sunday I have shoveled out the hives, but the snow between the barn and the hives requires walking 1/4 mile in 7 foot deep snow - challenging even with snowshoes. A stethoscope can be used to listen for �buzzing�, a crude measure of hive survival. My initial examination suggested that two of the twelve hives had not survived the unusually brutal winter. Clearly we needed to do an emergency inspection and decided that the 45F temperatures would be sufficient for a very quick look.
I carved a path to the hives and Kathy brought 18 sheets of fondant (sugar icing). One by one we opened each hive and added food. As we feared, two hives did not survive, but we found no clear evidence of nosema, american foulbrood, or heavy varroa mite loads. Once the weather warms we�ll look at all the hives, frame by frame.
One possibility is that the snow drifts were so high, the warmth of the sun from the south was blocked by the shadows of the enormous piles. Next week, the snowblower attachment for the front loader arrives and I�ll be carving paths, reducing drifts, and making management of the entire farm infinitely easier. I�ve worn out my alpine climbing gear by simply traversing the farm this winter. Using a commercial snowblower is a much better strategy than an ice ax, snow shoes, and total body vortex.
As March begins, I�m hopeful the snow will stop and the sun will shine, warming the hoop house to the point we can begin planting. Maybe next weekend I can finally get the peas in the ground. The lettuces, spinach, chard, bok choi, and mache have overwintered well - we�ll have our first harvest in early March.
Rabu, 25 Februari 2015
Making Time for Innovation
CIOs are at a challenging crossroads in their careers. Regulatory burdens, security threats, and changing reimbursement models have led to a demand for change that seems overwhelming. As workflow pressures increase, it�s easy to declare IT the rate limiting step.
Given that many CIOs are ready to raise the white flag of defeat in desperation, finding time for innovation amidst the swirl of must do projects can be a challenge.
My hope, and something I strive to do, is to take the long view, asking what innovations we�ll need in the next few years, which will enhance productivity, and possibly serve as generalizable tools, reducing the number of requests for niche systems. As I think about 2016, here are a few of the kinds of innovations I think we�ll want for healthcare organizations:
1. In our home lives, we use cloud hosted storage accessible on our personal devices. How can we give folks the same easy access to their files (in lieu of the SSLVPN web-based access) while still protecting patient privacy?
2. In our home lives, we use social networking - Facebook, LinkedIn, and Google+ to provide collaboration spaces for sharing ideas, messages, and files among groups. How do we offer these kind of applications to support our work lives? Is Slack a good fit for healthcare organizations?
3. In our home lives, we use texting for communication among teams. How do we deploy secure, enterprise grade texting that is fault tolerant, supports delegation (if you are unreachable), role-based messaging (the current administrator on call, whoever that is), and audibility. Per Harvard rules, I must disclose that I serve on the Board of Directors for Imprivata which produces such a product. I will recuse myself from any decision making processes about secure texting procurement.
4. As I�ve blogged about previously, patient generated healthcare data will become increasingly important and we need to be able to incorporate objective data (home devices) from smartphone middleware like HealthKit and subjective data (electronic patient reported outcomes).
5. Interoperability use cases will increasingly require closed loop transactions with tighter coupling among organizations. The FHIR work accelerated by the Argonauts group is the best path forward to achieve this goal.
As usual, sometimes we buy innovation and sometimes we build innovation. If practical, we should procure these services from cloud-based software as a service providers.
We need to work closely with our compliance and legal colleagues to balance risk and benefit, accepting that with all change and innovation there is a risk of the unknown. We can mitigate risk in the face of ambiguity.
Often organizations focus on the short term - the tyranny of the urgent. Carving out time for innovation with a long term view is necessary to create true breakthroughs. A dozen short term sprints will not add up to the marathon of transformation that is only accomplished via a steady pace over time.
Given that many CIOs are ready to raise the white flag of defeat in desperation, finding time for innovation amidst the swirl of must do projects can be a challenge.
My hope, and something I strive to do, is to take the long view, asking what innovations we�ll need in the next few years, which will enhance productivity, and possibly serve as generalizable tools, reducing the number of requests for niche systems. As I think about 2016, here are a few of the kinds of innovations I think we�ll want for healthcare organizations:
1. In our home lives, we use cloud hosted storage accessible on our personal devices. How can we give folks the same easy access to their files (in lieu of the SSLVPN web-based access) while still protecting patient privacy?
2. In our home lives, we use social networking - Facebook, LinkedIn, and Google+ to provide collaboration spaces for sharing ideas, messages, and files among groups. How do we offer these kind of applications to support our work lives? Is Slack a good fit for healthcare organizations?
3. In our home lives, we use texting for communication among teams. How do we deploy secure, enterprise grade texting that is fault tolerant, supports delegation (if you are unreachable), role-based messaging (the current administrator on call, whoever that is), and audibility. Per Harvard rules, I must disclose that I serve on the Board of Directors for Imprivata which produces such a product. I will recuse myself from any decision making processes about secure texting procurement.
4. As I�ve blogged about previously, patient generated healthcare data will become increasingly important and we need to be able to incorporate objective data (home devices) from smartphone middleware like HealthKit and subjective data (electronic patient reported outcomes).
5. Interoperability use cases will increasingly require closed loop transactions with tighter coupling among organizations. The FHIR work accelerated by the Argonauts group is the best path forward to achieve this goal.
As usual, sometimes we buy innovation and sometimes we build innovation. If practical, we should procure these services from cloud-based software as a service providers.
We need to work closely with our compliance and legal colleagues to balance risk and benefit, accepting that with all change and innovation there is a risk of the unknown. We can mitigate risk in the face of ambiguity.
Often organizations focus on the short term - the tyranny of the urgent. Carving out time for innovation with a long term view is necessary to create true breakthroughs. A dozen short term sprints will not add up to the marathon of transformation that is only accomplished via a steady pace over time.
Kamis, 19 Februari 2015
Unity Farm Journal - Third Week of February 2015
What happened to the term �polar vortex�? Are we now beyond it into something more severe? Unity Farm has not had a day above freezing or a night above the single digits (often negative single digits) in over a month. The most simple acts - walking to the hoop house, stacking supplies, and shoveling manure - require full alpine climbing gear.
Despite my hours in the Terex front loader creating a grand canyon of snow, it�s difficult to keep every aspect of the farm running. To understand the scale of our storms, imagine filling Patriots Stadium to the brim 90 times - and that is just the amount of snow removed from downtown Boston the past 30 days. The entire public transportation system will be shutdown/on limited schedule for the next month. And another storm is on the way for this weekend.
�Snow rage� abounds as commutes are measured in hours per mile, not miles per hour.
I can only hope that this winter does not become a standard experience. If it does, then the farm�s next capital purchase will be the snowblower attachment for the Terex.
No more, Mr. Nice Guy. A properly equipped Terex can blow 100 tons of snow per hour, 45 feet into the air. The idea of cruising along the farm roads and trails in the warmth of a the Terex cab, listening to Japanese flute music while slicing through 7 foot snow drifts sounds very appealing. I�ll keep it in mind for next season.
This year I split 8 cords of wood to keep the fireplaces toasty. My morning routine now consists of caring for the animals then hauling a hundred pounds of wood indoors so that it can thaw before nightfall. Who could have known that the neatly stacked wood would be 7 feet under non-melting snowbanks for the month of February?
I�m doing my best to offer grain/seeds to all the squirrels, turkeys and deer trying to survive the winter. How does a squirrel navigate a 7 foot snow pack? They must have talked to the moles, because we now have squirrel tunnels to the feeding areas.
This Sunday may include wintery mix - ice, snow and rain. The snow on the roofs currently weighs 5 pounds per cubic foot, but wet snow will weigh 21 pounds per cubic foot. I�m using a 20 foot snow rake to clear the sheds, barn and house before it comes icy concrete.
One advantage of this much snow is that it makes filling the bird feeders much easier. The 8 foot feeders are now at ground level.
Although the creatures are feeling claustrophobic, they are well fed and watered, which is key to their winter survival. I've carved a "duck highway" and covered it with straw, so they have a yellow brick road between the warm of their house and the extra food/water we've put out for all the birds.
Despite the hardship, the alpaca and llamas are getting dedicated attention. As one Alpaca farmer in New York posted
"I am head waiter at the Alpaca Fine Dining Restaurant located here in Western New York. For today's offering, we start with a fine appetizer of select grains served with a finely chopped, alfalfa chaffee hay salad. For our main course we offer delicious second cut orchard grass beautifully arrayed in our special "hay" feeders. To complement this, we offer slightly warmed fresh well water. I can expect a 20% tip of artfully arranged (and I might add frozen solid) alpaca beans. All's right with the world!!"
Despite my hours in the Terex front loader creating a grand canyon of snow, it�s difficult to keep every aspect of the farm running. To understand the scale of our storms, imagine filling Patriots Stadium to the brim 90 times - and that is just the amount of snow removed from downtown Boston the past 30 days. The entire public transportation system will be shutdown/on limited schedule for the next month. And another storm is on the way for this weekend.
I can only hope that this winter does not become a standard experience. If it does, then the farm�s next capital purchase will be the snowblower attachment for the Terex.
No more, Mr. Nice Guy. A properly equipped Terex can blow 100 tons of snow per hour, 45 feet into the air. The idea of cruising along the farm roads and trails in the warmth of a the Terex cab, listening to Japanese flute music while slicing through 7 foot snow drifts sounds very appealing. I�ll keep it in mind for next season.
This year I split 8 cords of wood to keep the fireplaces toasty. My morning routine now consists of caring for the animals then hauling a hundred pounds of wood indoors so that it can thaw before nightfall. Who could have known that the neatly stacked wood would be 7 feet under non-melting snowbanks for the month of February?
I�m doing my best to offer grain/seeds to all the squirrels, turkeys and deer trying to survive the winter. How does a squirrel navigate a 7 foot snow pack? They must have talked to the moles, because we now have squirrel tunnels to the feeding areas.
This Sunday may include wintery mix - ice, snow and rain. The snow on the roofs currently weighs 5 pounds per cubic foot, but wet snow will weigh 21 pounds per cubic foot. I�m using a 20 foot snow rake to clear the sheds, barn and house before it comes icy concrete.
One advantage of this much snow is that it makes filling the bird feeders much easier. The 8 foot feeders are now at ground level.
Although the creatures are feeling claustrophobic, they are well fed and watered, which is key to their winter survival. I've carved a "duck highway" and covered it with straw, so they have a yellow brick road between the warm of their house and the extra food/water we've put out for all the birds.
Despite the hardship, the alpaca and llamas are getting dedicated attention. As one Alpaca farmer in New York posted
"I am head waiter at the Alpaca Fine Dining Restaurant located here in Western New York. For today's offering, we start with a fine appetizer of select grains served with a finely chopped, alfalfa chaffee hay salad. For our main course we offer delicious second cut orchard grass beautifully arrayed in our special "hay" feeders. To complement this, we offer slightly warmed fresh well water. I can expect a 20% tip of artfully arranged (and I might add frozen solid) alpaca beans. All's right with the world!!"
Rabu, 18 Februari 2015
Mobile Applications Update
I have long believed that social networking concepts, mobile devices, analytics, and cloud are key tactics for the success of any IT organization. We�re in an era as significant as the mainframe to PC revolution in which BYOD devices and apps are becoming the platform of choice. Given the regulatory/compliance mandates for security, the need for auditability, and the need for provenance (can we trust the data?), implementing a mobile strategy in a healthcare environment can be tricky business.
Here�s an update on two projects we�re working on now that attempt to balance functionality with security.
We�ve written an iOS app that enables patients to connect their home devices with BIDMC clinical systems using HealthKit as middleware.
Below is a screen shots of the application in use. My staff have been testing it with electronic scales that report weight to HealthKit.
App users do a one time registration to give the BIDMC app permission to read values from Healthkit. They also login to our Personal Health Record, Patientsite, one time to enable upload. Then the App gets called by the iOS operating system whenever there is a new weight entry into Healthkit. The new weight entries (since last successful upload) are automatically uploaded and the user gets a notification of success.
Here�s how the data appears in the BIDMC systems. Each transaction is logged with a universal ID, date/time and provenance ensuring data integrity and traceability of each data element.
We�ll pilot the application and then enhance its usability based on lessons learned. We�ll continue our work to determine what alerts/reminders are sent to clinicians, care managers, and family members based on variation in the data provided by home devices. Weight changes can predict fluid retention leading to congestive heart failure exacerbations. Blood pressure tracking can support personalized adjustment of medications. Shared glucometer data can lead to better control of glucose over time. Very exciting possibilities.
One of the downsides of BYOD is that smartphone photography can lead to privacy issues such as revealing clinical information inappropriately, should the photograph become available on a social network or publicly available website. BIDMC is piloting a new camera created by Ricoh that uploads photos to the electronic health record and deletes them from the camera immediately, enabling photographs to be curated via the all the usual policy and technology controls surrounding the electronic health record.
If the pilot is successful, we can then change policy at BIDMC, requiring that purpose built, EHR connected, secure cameras be used for all clinical photography. The combination of technology and policy should reduce risk.
We continue to explore options to make our workforce more mobile, procuring services that enhance productivity and usability while protecting security and safety. More to come!
Here�s an update on two projects we�re working on now that attempt to balance functionality with security.
We�ve written an iOS app that enables patients to connect their home devices with BIDMC clinical systems using HealthKit as middleware.
Below is a screen shots of the application in use. My staff have been testing it with electronic scales that report weight to HealthKit.
Here�s how the data appears in the BIDMC systems. Each transaction is logged with a universal ID, date/time and provenance ensuring data integrity and traceability of each data element.
One of the downsides of BYOD is that smartphone photography can lead to privacy issues such as revealing clinical information inappropriately, should the photograph become available on a social network or publicly available website. BIDMC is piloting a new camera created by Ricoh that uploads photos to the electronic health record and deletes them from the camera immediately, enabling photographs to be curated via the all the usual policy and technology controls surrounding the electronic health record.
If the pilot is successful, we can then change policy at BIDMC, requiring that purpose built, EHR connected, secure cameras be used for all clinical photography. The combination of technology and policy should reduce risk.
We continue to explore options to make our workforce more mobile, procuring services that enhance productivity and usability while protecting security and safety. More to come!
Minggu, 15 Februari 2015
Snow Update from Unity Farm
In the past few hours, another 17 inches has fallen. The temperature is 10F, but headed to -10F tonight. We have 30 mph winds.
The creatures are warm and dry in the barn. All the feeders and waterers are full. I've picked fresh greens from the hoop house and given them to chickens, ducks, and guinea fowl.
How did I do this?
I put on my Mt. Washington climbing gear to exit the front door, where the snow level was higher than the door knob. The snow in the paddocks is over 7 feet high. The driveway piles are 10 feet high. The bee hives and apple trees were completely submerged by snow drifts and I dug them out with my avalanche rescue gear.
Is this Unity Farm or the Ernest Shackleton expedition?
The creatures are warm and dry in the barn. All the feeders and waterers are full. I've picked fresh greens from the hoop house and given them to chickens, ducks, and guinea fowl.
How did I do this?
I put on my Mt. Washington climbing gear to exit the front door, where the snow level was higher than the door knob. The snow in the paddocks is over 7 feet high. The driveway piles are 10 feet high. The bee hives and apple trees were completely submerged by snow drifts and I dug them out with my avalanche rescue gear.
Is this Unity Farm or the Ernest Shackleton expedition?
Kamis, 12 Februari 2015
Unity Farm Journal - Second Week of February 2015
Every time I step outside at Unity Farm, I want to sing �Let It Go, Let It Go�� since the world around is clearly Frozen. The icicles weigh more than 25 pounds. The Prius "snowmobile" is only visible by looking for the side mirror.
We�ve had over 72 inches of snow in the past 3 weeks. The top of the snow gauge is UNDER 3 feet of snow. The weather has been in the single digits, so no melting has happened. I�m 6 foot 2 and the snow drifts are now taller than me.
As an alpinist, I�ve climbed every peak in New England during winter. I�ve taken an engineering approach to clothing, reducing heat loss caused by conduction, radiation, and convection.
My morning animal care and farm maintenance requires a polyester base layer, Polartec Power shield, vortex, my ice climbing boots, and thick nylon gloves/gaiters.
Walking a mile on the farm at the moment is harder than climbing Mt. Washington in winter (the worst weather in the world).
The Terex front loader has been an essential tool since it enables me to create 8 foot high canyons of snow for the animals and to open up paths to buildings/supplies. I�ve been using 10 gallons of diesel per week just to clear snow/ice. We�re expecting another foot of snow today and there is no place left to put it, so I�m converting one of the pastures to a snow parking lot.
Llamas and alpacas live in the Andes, a dry/cold area. They are comfortable with temps below zero, but really do not like navigating deep snow. The Terex and the snow blower together have been enable to create paths and create areas for eating/sleeping outside the barn. They spend storm days inside the barn, but have cabin fever, and want to run, which is difficult in 6 foot deep frozen quicksand.
Our chickens are bred for cold climates and do not mind chilly temperatures, but they find the wetness of winter unpleasant. The ducks seem like stay outdoors in all conditions except blizzard conditions which they ride out in their duck house. The guinea fowl, our flying dinosaurs, seem capable of handling any �fowl� weather.
The Great Pyrenees dig, role, and relish the snow. They are in 6 feet of heaven.
I use my avalanche shovel to keep the bee hives clear of snow. I�ve felt like a Sisyphus shoveling snow away from the hives every night, then waking to find them covered again.
As the next storm approaches, the sand barrels are filled will 100 pounds of dry, general purpose sand. Five hundred pounds of calcium chloride/magnesium chloride are stacked in the barn, ready for safe ice melting around vegetation. The diesel and gas tanks/storage are full. The shovels are placed near each key doorway. I even removed a pasture gate so that the new �snow parking lot� will not be blocked by a snow covered barrier.
The next few days will see high temperatures below 10F and lows below -10F. This week I replaced the heater base for our water fonts in the coop - they failed from overuse.
As my wife says �The Winter of 2015 - I�m ready to Let It Go!�
We�ve had over 72 inches of snow in the past 3 weeks. The top of the snow gauge is UNDER 3 feet of snow. The weather has been in the single digits, so no melting has happened. I�m 6 foot 2 and the snow drifts are now taller than me.
As an alpinist, I�ve climbed every peak in New England during winter. I�ve taken an engineering approach to clothing, reducing heat loss caused by conduction, radiation, and convection.
My morning animal care and farm maintenance requires a polyester base layer, Polartec Power shield, vortex, my ice climbing boots, and thick nylon gloves/gaiters.
Walking a mile on the farm at the moment is harder than climbing Mt. Washington in winter (the worst weather in the world).
The Terex front loader has been an essential tool since it enables me to create 8 foot high canyons of snow for the animals and to open up paths to buildings/supplies. I�ve been using 10 gallons of diesel per week just to clear snow/ice. We�re expecting another foot of snow today and there is no place left to put it, so I�m converting one of the pastures to a snow parking lot.
Llamas and alpacas live in the Andes, a dry/cold area. They are comfortable with temps below zero, but really do not like navigating deep snow. The Terex and the snow blower together have been enable to create paths and create areas for eating/sleeping outside the barn. They spend storm days inside the barn, but have cabin fever, and want to run, which is difficult in 6 foot deep frozen quicksand.
Our chickens are bred for cold climates and do not mind chilly temperatures, but they find the wetness of winter unpleasant. The ducks seem like stay outdoors in all conditions except blizzard conditions which they ride out in their duck house. The guinea fowl, our flying dinosaurs, seem capable of handling any �fowl� weather.
The Great Pyrenees dig, role, and relish the snow. They are in 6 feet of heaven.
I use my avalanche shovel to keep the bee hives clear of snow. I�ve felt like a Sisyphus shoveling snow away from the hives every night, then waking to find them covered again.
As the next storm approaches, the sand barrels are filled will 100 pounds of dry, general purpose sand. Five hundred pounds of calcium chloride/magnesium chloride are stacked in the barn, ready for safe ice melting around vegetation. The diesel and gas tanks/storage are full. The shovels are placed near each key doorway. I even removed a pasture gate so that the new �snow parking lot� will not be blocked by a snow covered barrier.
The next few days will see high temperatures below 10F and lows below -10F. This week I replaced the heater base for our water fonts in the coop - they failed from overuse.
As my wife says �The Winter of 2015 - I�m ready to Let It Go!�
Selasa, 10 Februari 2015
The February HIT Standards/HIT Policy Joint Meeting
The February HIT Standards Committee was a joint meeting with the HIT Policy Committee to align the policy and technology work ahead in 2015.
Erica Galvez began the discussion by reviewing the recently published Interoperability Roadmap. She first highlighted supportive business, clinical, cultural and regulatory environments:
*On January 26, HHS and CMS announced that they are aiming to have 30 percent of Medicare fee-for-service payments tied to quality or value through alternative payment models by the end of 2016,and 50 percent of payments by the end of 2018.
*Requirements for participants in these new models can reinforce interoperability.
*Near term actions for the Federal government include linking policy and funding activities beyond Meaningful Use to adoption and use of certified health IT and electronic information sharing according to national standards.
*Near term actions for state government include a �call to action� to use available levers and Medicaid purchasing power to expand upon existing efforts to support interoperability and explore new options.
*Near term actions for non-government payers/purchasers include a �call to action� to explore financial incentives and other ways to emphasize the interoperable exchange of health information among provider networks.
Erica continued with a discussion of governance, emphasizing the need for a framework than a new organization with �top down� authority.
She then continued with an overview of privacy and security protections for health information including the need to address the variation in state rules which make it difficult to build software systems that accurately capture, maintain, and persist consent data. ONC�s role is to help facilitate the alignment of policy among all stakeholders.
We then discussed the core technical standards/functions and certification/testing to support adoption and optimization of health IT products and services. Near term actions include ONC�s effort to publish annual list of best available technical standards for core interoperability functions. The private and public sectors must:
� Define a common clinical data set to achieve semantic
interoperability
� Constrain implementation of the C-CDA
� Advance standards for data provenance at the document and data element
level
� Advance standard, open RESTful APIs to support simple, scalable
interoperability
Erica concluded with a discussion of the next steps. Workgroups were assigned sections of the roadmap to review to make the best use of resources and avoid overlap.
Steve Posnack continued with an overview of the recently published Standards Advisory document. The goals of the Advisory are to be specific about the best standards available for each purpose. It�s a non-regulatory approach with an interactive, predictable process. Hopefully it will be a widely vetted resource that will enable a �look first� philosophy for government programs, procurements, testing or certification programs, and standards development.
Steve then provided a Certification Program update including plans for quality improvement, greater transparency, increased collaboration, and improved customer service.
Finally, Dawn Heisey-Grove and Elisabeth Myers provided an update on Meaningful Use attestations.
A great meeting with many next steps. It�s clear that interoperability will significantly increase when the right standards, supported by constrained implementation guides, are paired with consent/security policies widely accepted by all stakeholders.
Erica Galvez began the discussion by reviewing the recently published Interoperability Roadmap. She first highlighted supportive business, clinical, cultural and regulatory environments:
*On January 26, HHS and CMS announced that they are aiming to have 30 percent of Medicare fee-for-service payments tied to quality or value through alternative payment models by the end of 2016,and 50 percent of payments by the end of 2018.
*Requirements for participants in these new models can reinforce interoperability.
*Near term actions for the Federal government include linking policy and funding activities beyond Meaningful Use to adoption and use of certified health IT and electronic information sharing according to national standards.
*Near term actions for state government include a �call to action� to use available levers and Medicaid purchasing power to expand upon existing efforts to support interoperability and explore new options.
*Near term actions for non-government payers/purchasers include a �call to action� to explore financial incentives and other ways to emphasize the interoperable exchange of health information among provider networks.
Erica continued with a discussion of governance, emphasizing the need for a framework than a new organization with �top down� authority.
She then continued with an overview of privacy and security protections for health information including the need to address the variation in state rules which make it difficult to build software systems that accurately capture, maintain, and persist consent data. ONC�s role is to help facilitate the alignment of policy among all stakeholders.
We then discussed the core technical standards/functions and certification/testing to support adoption and optimization of health IT products and services. Near term actions include ONC�s effort to publish annual list of best available technical standards for core interoperability functions. The private and public sectors must:
� Define a common clinical data set to achieve semantic
interoperability
� Constrain implementation of the C-CDA
� Advance standards for data provenance at the document and data element
level
� Advance standard, open RESTful APIs to support simple, scalable
interoperability
Erica concluded with a discussion of the next steps. Workgroups were assigned sections of the roadmap to review to make the best use of resources and avoid overlap.
Steve Posnack continued with an overview of the recently published Standards Advisory document. The goals of the Advisory are to be specific about the best standards available for each purpose. It�s a non-regulatory approach with an interactive, predictable process. Hopefully it will be a widely vetted resource that will enable a �look first� philosophy for government programs, procurements, testing or certification programs, and standards development.
Steve then provided a Certification Program update including plans for quality improvement, greater transparency, increased collaboration, and improved customer service.
Finally, Dawn Heisey-Grove and Elisabeth Myers provided an update on Meaningful Use attestations.
A great meeting with many next steps. It�s clear that interoperability will significantly increase when the right standards, supported by constrained implementation guides, are paired with consent/security policies widely accepted by all stakeholders.
Kamis, 05 Februari 2015
Unity Farm Journal - First week of February 2015
We�ve had nearly 4 feet of snow this week, sub zero temperatures and high winds. The barnyard looks like the grand canyon with piles of snow 7 feet high. The Terex PT-30 Compact Track Loader can lift 1000 pounds of snow at a time and we�ve cleared 2 acres of snow for all the creatures that live on the farm.
My years as an alpinist (pictured below) have prepared me well for shoveling manure in the dark at sub zero temperatures. As a farmer, I cannot sleep in, wear my bunny slippers and sip tea by the fire. Every morning, over 100 lives depend on me to feed them, provider water, and clean their living spaces. At the moment, every creature is warm, dry, hydrated, well feed, and loved.
The driveway to Unity farm is a quarter mile long. It�s just the same as shoveling your driveway, with a different scale. When 4 feet of snow fall, the issue is not finding someone to plow. The issue is finding somewhere to store all that snow.
The hoop house vegetables continue to grow under their row covers even in the subzero temps. Spinach, Romaine, and Winter Density Lettuce are particularly successful. I pick them every day for the humans and the creatures which all enjoy their greens in the depth of winter.
The bird feeders are filled with high calorie seeds and suet. Dozens of species visit the farm every day for food, water, and warmth. I find Carolina wrens, sparrows, and blue birds sleeping in the barn every morning.
The work of keeping a farm productive in the winter requires attention to detail - shoveling around the generator, keeping the bee hives well ventilated by clearing snow, using additives in gasoline and diesel to keep the machinery running, splitting wood every day, and heating all forms of water to keep the animals hydrated.
This winter is proving to be more difficult than the last, but thus far, everyone is healthy and happy. My productivity given a 4 bar LTE connection to mobile devices, a high speed fiber network on the farm, and multiple teleconferencing modalities has worked seamlessly, so that every part of my work life has continued through the storms without missing a beat.
The next week will be marked by more snow and continuing subzero temperatures. I look forward to the end of snow management and the beginning of early spring indoor seed germination in the weeks ahead.
My years as an alpinist (pictured below) have prepared me well for shoveling manure in the dark at sub zero temperatures. As a farmer, I cannot sleep in, wear my bunny slippers and sip tea by the fire. Every morning, over 100 lives depend on me to feed them, provider water, and clean their living spaces. At the moment, every creature is warm, dry, hydrated, well feed, and loved.
The driveway to Unity farm is a quarter mile long. It�s just the same as shoveling your driveway, with a different scale. When 4 feet of snow fall, the issue is not finding someone to plow. The issue is finding somewhere to store all that snow.
The hoop house vegetables continue to grow under their row covers even in the subzero temps. Spinach, Romaine, and Winter Density Lettuce are particularly successful. I pick them every day for the humans and the creatures which all enjoy their greens in the depth of winter.
The bird feeders are filled with high calorie seeds and suet. Dozens of species visit the farm every day for food, water, and warmth. I find Carolina wrens, sparrows, and blue birds sleeping in the barn every morning.
The work of keeping a farm productive in the winter requires attention to detail - shoveling around the generator, keeping the bee hives well ventilated by clearing snow, using additives in gasoline and diesel to keep the machinery running, splitting wood every day, and heating all forms of water to keep the animals hydrated.
This winter is proving to be more difficult than the last, but thus far, everyone is healthy and happy. My productivity given a 4 bar LTE connection to mobile devices, a high speed fiber network on the farm, and multiple teleconferencing modalities has worked seamlessly, so that every part of my work life has continued through the storms without missing a beat.
The next week will be marked by more snow and continuing subzero temperatures. I look forward to the end of snow management and the beginning of early spring indoor seed germination in the weeks ahead.
Selasa, 03 Februari 2015
The athenahealth/BIDMC Collaboration
BIDMC has self-developed its core clinical information systems for many years. We certified all our applications for the 2011 and 2014 ONC criteria, attesting to Meaningful Use Stage 1 and 2 in every appropriate year. BIDMC has hundreds of person-years invested in our web-based, cloud-hosted in-patient and out-patient applications. The culture of BIDMC has always been to challenge to the status quo, to be willing to be a first mover, and to focus on value�establishing the highest quality at the lowest cost.
But the days of self-built systems cannot last forever. While we want to continue to innovate, we know that commercial vendors will be able to leverage their knowledge and capabilities to build future platforms at larger scale.
We know those platforms will need to support evolving capabilities. I have long believed that the key to the future of healthcare involves maintaining wellness across the continuum of care, not optimizing the treatment of episodic sickness in silo-ed organizations. Academic medical centers are important for research and education, but the majority of care can be delivered safely in community hospitals and practices near the home, at lower cost. The HIT software of the future needs to leverage the experience of internet centric companies, offering cloud-hosted services with a zero client footprint, easily deployable in all sites of care. There should be no special browser, desktop, or infrastructure requirements. The services should be delivered via a subscription model that can be easily turned on and off as needed. Products should include practice management, billing, a patient/clinician inpatient/outpatient shared medical record, care management, population health, and an app store of third party developed mobile products.
During my life in New England, I�ve had the opportunity to work with several professors specializing in negotiation theory. I�ve learned about the importance of aligned interests. ??athenahealth is a cloud-hosted service provider with billing, ambulatory clinical, and population health products. It has a culture of rapid cycle improvement and disruptive innovation.
For all of these reasons, BIDMC and athenahealth announced a new and unique collaboration. The collaboration between the two organizations provides athenahealth the chance to take BIDMC�s experience to a much larger audience, hopefully making a difference to providers, patients, and payers across the country. athenahealth will also accelerate its ability to develop expanded functionality more rapidly than doing it alone.
I have always served as Geneva, a neutral convener. I hope that the industry understands that I will not receive any compensation or personal benefit from the collaboration. I do not and cannot own any athenahealth stock. BIDMC will not write code for athenahealth�s new products nor receive royalties. BIDMC�s community hospitals will continue to implement the cloud hosted, web-enabled Meditech version 6.1x for inpatient support. Many BIDMC community practices use eClinicalWorks.
Over the next 5 years at BIDMC, we will select the best products and best services that meet the needs of our highly diverse network. athenahealth products will be piloted in outpatient and inpatient locations. We certainly hope that athenahealth produces excellent products but at BIDMC, we are a meritocracy and the best services at the lowest cost will win.
Just as Mayo chose Epic to reduce the number of different IT systems, BIDMC will pursue a parsimony solution - the fewest moving parts possible. That might be one vendor, but hopefully it will not be more than two.
I look forward to seeing what happens as webOMR moves from a 25 person development team to a 1500 person development team.
The future belongs to social, mobile, analytics, and cloud. The transfer of our self-developed software to athenahealth will give the industry a unique opportunity to explore the cutting edge of the possible.
But the days of self-built systems cannot last forever. While we want to continue to innovate, we know that commercial vendors will be able to leverage their knowledge and capabilities to build future platforms at larger scale.
We know those platforms will need to support evolving capabilities. I have long believed that the key to the future of healthcare involves maintaining wellness across the continuum of care, not optimizing the treatment of episodic sickness in silo-ed organizations. Academic medical centers are important for research and education, but the majority of care can be delivered safely in community hospitals and practices near the home, at lower cost. The HIT software of the future needs to leverage the experience of internet centric companies, offering cloud-hosted services with a zero client footprint, easily deployable in all sites of care. There should be no special browser, desktop, or infrastructure requirements. The services should be delivered via a subscription model that can be easily turned on and off as needed. Products should include practice management, billing, a patient/clinician inpatient/outpatient shared medical record, care management, population health, and an app store of third party developed mobile products.
During my life in New England, I�ve had the opportunity to work with several professors specializing in negotiation theory. I�ve learned about the importance of aligned interests. ??athenahealth is a cloud-hosted service provider with billing, ambulatory clinical, and population health products. It has a culture of rapid cycle improvement and disruptive innovation.
For all of these reasons, BIDMC and athenahealth announced a new and unique collaboration. The collaboration between the two organizations provides athenahealth the chance to take BIDMC�s experience to a much larger audience, hopefully making a difference to providers, patients, and payers across the country. athenahealth will also accelerate its ability to develop expanded functionality more rapidly than doing it alone.
I have always served as Geneva, a neutral convener. I hope that the industry understands that I will not receive any compensation or personal benefit from the collaboration. I do not and cannot own any athenahealth stock. BIDMC will not write code for athenahealth�s new products nor receive royalties. BIDMC�s community hospitals will continue to implement the cloud hosted, web-enabled Meditech version 6.1x for inpatient support. Many BIDMC community practices use eClinicalWorks.
Over the next 5 years at BIDMC, we will select the best products and best services that meet the needs of our highly diverse network. athenahealth products will be piloted in outpatient and inpatient locations. We certainly hope that athenahealth produces excellent products but at BIDMC, we are a meritocracy and the best services at the lowest cost will win.
Just as Mayo chose Epic to reduce the number of different IT systems, BIDMC will pursue a parsimony solution - the fewest moving parts possible. That might be one vendor, but hopefully it will not be more than two.
I look forward to seeing what happens as webOMR moves from a 25 person development team to a 1500 person development team.
The future belongs to social, mobile, analytics, and cloud. The transfer of our self-developed software to athenahealth will give the industry a unique opportunity to explore the cutting edge of the possible.
Jumat, 30 Januari 2015
The Interoperability Roadmap
On Thursday, CMS announced their intent to update the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs for 2015 and beyond, reducing the reporting burden on providers, while supporting the long term goals of the program.
On Friday, ONC released the Interoperability Roadmap and the Standards Advisory.
A busy week. What does it all mean?
The CMS announcement includes planning for a Spring 2015 rule that:
*Realigns hospital EHR reporting periods to the calendar year to allow eligible hospitals more time to incorporate 2014 Edition software into their workflows and to better align with other CMS quality programs.
*Modifies other aspects of the program to match long-term goals, reduce complexity, and lessen providers� reporting burdens.
*Shortens the EHR reporting period in 2015 to 90 days to accommodate these changes.
It�s a positive sign that HHS leaders are listening and responding to stakeholders. Meaningful Use Stage 2 contains numerous goals that require an ecosystem/marketplace to develop first. The HIE marketplace is just developing and usable apps for patient view/download/transmit are still 6 months away. The new timeline gives us the flexibility we need to do these projects right, leveraging the market foundation that is developing.
The draft Interoperability Roadmap released by ONC describes the current market and issues in interoperability.
It aligns well with the work of the Jason Task Force, recognizing the role of the private sector and the importance of market-based networks. It supports the move to modern internet interoperability conventions (including RESTful APIs like FHIR)
It wisely suggests �non-government governance� for health information exchange rather than trying to create a single top-down nationwide governance entity.
It focuses on the importance of clarifying HIPAA to reduce confusion and misconceptions about HIPAA restrictions and enablers. For example, does everyone know there is no such thing as HIPAA certified software and there are no restrictions on giving patients access to their own data?
The Roadmap does have a few areas of concern. It suggests that States become more active in the area of interoperability. We need to be careful with this approach or else we�ll create 50 interoperability silos given variation in State laws. The new economic incentives of accountable care organizations will motivate vendors to address health information exchange needs based on business cases, not geography.
The Roadmap needs to describe a few more concrete steps that government should take to support the listed goals. Increasing value-based purchasing and having federal agencies accelerate standards-based interoperability are very good, but there are other levers to consider such as creating reusable components at scale (i.e. a nationwide provider directory), aligning quality measurement programs/aligning quality measure reporting with modern interoperability standards, and harmonizing other health care regulations with interoperability conventions (i.e. community health center, nursing home, and home health reporting and regulation).
ONC is currently accepting public comments and key commitments on the draft Roadmap for approximately 60 days which will end at 5pm ET on April 3, 2015.
The �Standards Advisory� companion document does specify some standards that are mature or becoming mature such as HL7 2.x, CCDA, and FHIR. However, it also includes standards that are not likely to achieve maturity based on the objective criteria outlined by the HIT Standards Committee. I would advocate for leaving some of the boxes blank, since no mature or becoming mature standards are available for them.
Overall, I give ONC kudos for their articulate summary of where the federal government would like the industry to focus. The market is making tremendous progress at this point, and the roadmap is a useful directional guide.
On Friday, ONC released the Interoperability Roadmap and the Standards Advisory.
A busy week. What does it all mean?
The CMS announcement includes planning for a Spring 2015 rule that:
*Realigns hospital EHR reporting periods to the calendar year to allow eligible hospitals more time to incorporate 2014 Edition software into their workflows and to better align with other CMS quality programs.
*Modifies other aspects of the program to match long-term goals, reduce complexity, and lessen providers� reporting burdens.
*Shortens the EHR reporting period in 2015 to 90 days to accommodate these changes.
It�s a positive sign that HHS leaders are listening and responding to stakeholders. Meaningful Use Stage 2 contains numerous goals that require an ecosystem/marketplace to develop first. The HIE marketplace is just developing and usable apps for patient view/download/transmit are still 6 months away. The new timeline gives us the flexibility we need to do these projects right, leveraging the market foundation that is developing.
The draft Interoperability Roadmap released by ONC describes the current market and issues in interoperability.
It aligns well with the work of the Jason Task Force, recognizing the role of the private sector and the importance of market-based networks. It supports the move to modern internet interoperability conventions (including RESTful APIs like FHIR)
It wisely suggests �non-government governance� for health information exchange rather than trying to create a single top-down nationwide governance entity.
It focuses on the importance of clarifying HIPAA to reduce confusion and misconceptions about HIPAA restrictions and enablers. For example, does everyone know there is no such thing as HIPAA certified software and there are no restrictions on giving patients access to their own data?
The Roadmap does have a few areas of concern. It suggests that States become more active in the area of interoperability. We need to be careful with this approach or else we�ll create 50 interoperability silos given variation in State laws. The new economic incentives of accountable care organizations will motivate vendors to address health information exchange needs based on business cases, not geography.
The Roadmap needs to describe a few more concrete steps that government should take to support the listed goals. Increasing value-based purchasing and having federal agencies accelerate standards-based interoperability are very good, but there are other levers to consider such as creating reusable components at scale (i.e. a nationwide provider directory), aligning quality measurement programs/aligning quality measure reporting with modern interoperability standards, and harmonizing other health care regulations with interoperability conventions (i.e. community health center, nursing home, and home health reporting and regulation).
ONC is currently accepting public comments and key commitments on the draft Roadmap for approximately 60 days which will end at 5pm ET on April 3, 2015.
The �Standards Advisory� companion document does specify some standards that are mature or becoming mature such as HL7 2.x, CCDA, and FHIR. However, it also includes standards that are not likely to achieve maturity based on the objective criteria outlined by the HIT Standards Committee. I would advocate for leaving some of the boxes blank, since no mature or becoming mature standards are available for them.
Overall, I give ONC kudos for their articulate summary of where the federal government would like the industry to focus. The market is making tremendous progress at this point, and the roadmap is a useful directional guide.
Kamis, 29 Januari 2015
Unity Farm Journal - The 5th Week of January 2015
Several people have emailed me asking about my well being, given that my blog posts have been delayed this week. I�m fine - my excuse is snow. 30 inches over 15 acres is a lot of snow to move.
From Tuesday to Wednesday this week, we had �Stormageddon�, zero degree temperatures, 40 mile per hour winds, and nearly 3 feet of snow in a 24 hour period. The roads were closed and all the doors on the farm were blocked. We were saved by the Terex front loader, which can move 1000 pounds of snow (or manure) at a time.
I spent Wednesday doing storm cleanup, carving a barnyard for the ducks, chickens, and guinea fowl, creating paths for the alpaca between the barn and the hay feeders, and ensuring the dogs had a place to run. I shoveled out bee yard so that all 12 hives had open ventilation on all sides. I cleared the driveways, gates, and paths around the house.
We kept the animals dry and warm. We gave them extra food and water. We use the Terex to move manure from the barn to the compost area.
We were very prepared for this winter, with all the right tools, supplies and infrastructure to deal with it. We had spent numerous weekends doing woodland management to prevent the collapse of dead or dying trees. We filled all our gas, diesel, and propane tanks to the top. We ensured we had spare food supplies for us and all the creatures.
Below are a few photos of the farm at the depth of winter. Now that tons of snow are cleared, I can return to blogging about the recently released ONC Interoperability Roadmap, Standards Advisory, and CMS revisions to Meaningful Use - coming soon!
Here's what 30 inches of snow looks like
The alpaca like cold, but do not like snow
The Great Pyrenees love snow
and here's a movie of what they like to do in it.
The Apple Orchard is covered in a thick white blanket
And more snow arrives tonight. Where will I put it?
From Tuesday to Wednesday this week, we had �Stormageddon�, zero degree temperatures, 40 mile per hour winds, and nearly 3 feet of snow in a 24 hour period. The roads were closed and all the doors on the farm were blocked. We were saved by the Terex front loader, which can move 1000 pounds of snow (or manure) at a time.
I spent Wednesday doing storm cleanup, carving a barnyard for the ducks, chickens, and guinea fowl, creating paths for the alpaca between the barn and the hay feeders, and ensuring the dogs had a place to run. I shoveled out bee yard so that all 12 hives had open ventilation on all sides. I cleared the driveways, gates, and paths around the house.
We kept the animals dry and warm. We gave them extra food and water. We use the Terex to move manure from the barn to the compost area.
We were very prepared for this winter, with all the right tools, supplies and infrastructure to deal with it. We had spent numerous weekends doing woodland management to prevent the collapse of dead or dying trees. We filled all our gas, diesel, and propane tanks to the top. We ensured we had spare food supplies for us and all the creatures.
Below are a few photos of the farm at the depth of winter. Now that tons of snow are cleared, I can return to blogging about the recently released ONC Interoperability Roadmap, Standards Advisory, and CMS revisions to Meaningful Use - coming soon!
Here's what 30 inches of snow looks like
The alpaca like cold, but do not like snow
The Great Pyrenees love snow
and here's a movie of what they like to do in it.
The Apple Orchard is covered in a thick white blanket
And more snow arrives tonight. Where will I put it?
Rabu, 28 Januari 2015
The January HIT Standards Committee
The January HIT Standards Committee focused on two important topics, the future of the Standards and Interoperability (S&I) Framework and the xtandards needed for provenance i.e. who generated the data and I can I trust it?
Stan Huff and Arien Malec presented the process that the Standards & Interoperability Task Force will use to evaluate the best way to harmonize standards in the future. Typically Standards Development Organizations (SDOs) create and curate standards but sometimes there is a need to select among competing standards or combine the work of multiple SDOs into an implementation guide. The Healthcare IT Standards Panel (HITSP) did this kind of harmonization. When HITSP was sunsetted during the transition from the Bush to the Obama administration, the S&I Framework was created to fill the harmonization role, since the Healthcare IT Standards Committee (HITSC) served in advisory capacity to ONC, not doing the granular work of implementation guide writing. Questions to be asked by the Task Force include:
Is there a continued need for the S&I Framework (or an equivalent process) to advance standards and implementation specification development?
The task force will evaluate the �What� (what should be done) and the �How� (by whom, in what forum, with what processes)
We all look forward to their work.
Lisa Gallagher presented the work of the Data Provenance Task Force. Their remarkable set of recommendations that were applauded by all.
The Task Force recommended that the Data Provenance Initiative should focus on the following:
Where did the data come from? (�source provenance�)
Has it been changed?
Can I trust the data?
The Task Force recommended that these questions be answered using 4 transaction types, in the following order of priority (although they are roughly equal in priority)
*With exchange of data between EHRs
*At the point of origin/data creation in an EHR or HIE
*With the transfer of data from a Patient Controlled Device (PCD) or a Personal Health Record (PHR) to an EHR system
*At the point of data creation in a PCD or PHR
They recommended that the CCDA and FHIR be the target technologies for provenance standards taking into account existing work including
*CDA/C-CDA Provenance
*FHIR Provence Project
*Privacy on FHIR Projects
Finally, they recommended that for health information exchange, both push (Direct) and pull (SOAP/REST query/response), that the provenance of the content should be lossless ie. there is data integrity from the point of origin to the point of use.
Much discussion followed and the Committee agreed that we needed to define lossless i.e. what if the data is mapped into a different vocabulary or different format? Arien Malec agreed to prepare a straw man definition of lossless.
The committee voted to support these recommendations and formally deliver them to ONC.
The next few months will be very busy for the HIT Standards Committee as we review the Federal HIT Stategic Plan, the Ten Year Interoperability Roadmap, and the Meaningful Use Stage 3 Notice of Proposed Rulemaking. Exciting times ahead.
Stan Huff and Arien Malec presented the process that the Standards & Interoperability Task Force will use to evaluate the best way to harmonize standards in the future. Typically Standards Development Organizations (SDOs) create and curate standards but sometimes there is a need to select among competing standards or combine the work of multiple SDOs into an implementation guide. The Healthcare IT Standards Panel (HITSP) did this kind of harmonization. When HITSP was sunsetted during the transition from the Bush to the Obama administration, the S&I Framework was created to fill the harmonization role, since the Healthcare IT Standards Committee (HITSC) served in advisory capacity to ONC, not doing the granular work of implementation guide writing. Questions to be asked by the Task Force include:
Is there a continued need for the S&I Framework (or an equivalent process) to advance standards and implementation specification development?
The task force will evaluate the �What� (what should be done) and the �How� (by whom, in what forum, with what processes)
We all look forward to their work.
Lisa Gallagher presented the work of the Data Provenance Task Force. Their remarkable set of recommendations that were applauded by all.
The Task Force recommended that the Data Provenance Initiative should focus on the following:
Where did the data come from? (�source provenance�)
Has it been changed?
Can I trust the data?
The Task Force recommended that these questions be answered using 4 transaction types, in the following order of priority (although they are roughly equal in priority)
*With exchange of data between EHRs
*At the point of origin/data creation in an EHR or HIE
*With the transfer of data from a Patient Controlled Device (PCD) or a Personal Health Record (PHR) to an EHR system
*At the point of data creation in a PCD or PHR
They recommended that the CCDA and FHIR be the target technologies for provenance standards taking into account existing work including
*CDA/C-CDA Provenance
*FHIR Provence Project
*Privacy on FHIR Projects
Finally, they recommended that for health information exchange, both push (Direct) and pull (SOAP/REST query/response), that the provenance of the content should be lossless ie. there is data integrity from the point of origin to the point of use.
Much discussion followed and the Committee agreed that we needed to define lossless i.e. what if the data is mapped into a different vocabulary or different format? Arien Malec agreed to prepare a straw man definition of lossless.
The committee voted to support these recommendations and formally deliver them to ONC.
The next few months will be very busy for the HIT Standards Committee as we review the Federal HIT Stategic Plan, the Ten Year Interoperability Roadmap, and the Meaningful Use Stage 3 Notice of Proposed Rulemaking. Exciting times ahead.
Kamis, 22 Januari 2015
Unity Farm Journal - 4th week of January 2015
The cold of late January has been hard on our living things and we�ve sorted all our produce to eliminate cold damaged fruits/vegetables in the hoop house, root cellar, and forest.
The apples from this year�s harvest are still fairing well. Empire, Macoun, Winesap, RedSpy, and Rome are still crisp. The Spencer apples have softened and are beginning to mold. We composted about half a bushel.
The root vegetables - beets, daikon radish, and turnips were kept in soil until late December. At the moment, they are still crisp and fresh, ready to be turned into soups, salads, and canning.
The squash harvested in October has started to develop mold and soft spots. The ducks and chickens enjoy them, so we split the squash and laid them out for the poultry.
All our seed catalogs have arrived and with last week�s seed planning, we�re ordering everything for our first planting in March.
As usual, we continued harvesting wood, splitting logs, and maintaining the property this week. I look back on the past two years and I�m amazed at how far we�ve come, dedicating every weekend to maintaining the land.
We walked the property and planned our 2015 permaculture planting. The new chestnut trees will go in along our northern border. The paw paw trees will be planted in the understory behind the cider house. The rice will be tested in a low-lying portion of the orchard.
This weekend will be focused on more indoor tasks - maybe we�ll get to the skirting of alpaca fiber so we can produce the yarn from our 2014 sheering. A farmer�s work is never done.
The apples from this year�s harvest are still fairing well. Empire, Macoun, Winesap, RedSpy, and Rome are still crisp. The Spencer apples have softened and are beginning to mold. We composted about half a bushel.
The root vegetables - beets, daikon radish, and turnips were kept in soil until late December. At the moment, they are still crisp and fresh, ready to be turned into soups, salads, and canning.
The squash harvested in October has started to develop mold and soft spots. The ducks and chickens enjoy them, so we split the squash and laid them out for the poultry.
All our seed catalogs have arrived and with last week�s seed planning, we�re ordering everything for our first planting in March.
As usual, we continued harvesting wood, splitting logs, and maintaining the property this week. I look back on the past two years and I�m amazed at how far we�ve come, dedicating every weekend to maintaining the land.
We walked the property and planned our 2015 permaculture planting. The new chestnut trees will go in along our northern border. The paw paw trees will be planted in the understory behind the cider house. The rice will be tested in a low-lying portion of the orchard.
This weekend will be focused on more indoor tasks - maybe we�ll get to the skirting of alpaca fiber so we can produce the yarn from our 2014 sheering. A farmer�s work is never done.
Rabu, 21 Januari 2015
The Experience of Interoperability Thus Far
As I travel across the country and listen to CIOs struggling with mandates from Meaningful Use to ICD-10 to the HIPAA Omnibus rule to the Affordable Care Act, I'm always looking for ways to reduce the burden on IT leaders.
All have expressed frustration with the health information exchange (HIE) policies and technologies for care coordination. quality measurement, and patient engagement.
As a country, what can we do to reduce this anxiety?
Meaningful Use Stage 1 brought some interoperability especially around public health reporting. Stage 2 brought additional interoperability, with well defined content, vocabulary, and transport standards for transitions of care.
Most CIOs have implemented certified EHRs and the required standards. Here�s a capsule summary of what I�ve heard
HL7 2.x
HL7 messaging addresses lab result and public health use cases very well. Lab results interfaces are straight forward, however there is still some need to reduce optionality in implementation guides so that the average lab interface costs $500 and not $5000. Public health transactions for immunizations, reportable lab, and syndromic surveillance are standardized from a content perspective but there is still a need to specify a single transport mechanism for all public health agencies.
CCDA/Direct
CCDA documents address transitions of care use cases reasonably well. CCDA is easier to work and
parse than CCD/C32 because it has additional constraints and specifications, but there is still enough optionality that merging CCDA data into an EHR can be challenging. In addition, most EHRs generate a CCDA automatically and include all data that may possibly be relevant. In some cases, this leads to C-CDAs that are rendered at 50+ pages. We need to reduce optionality so that CCDAs are easier to generate correctly and parse. EHR workflow needs to better support the creation of clinically relevant documents with narrative and data more specific to transitions.
Direct was a good first step for transport - we needed to pick something. We could have required sFTP, REST, SOAP, SMTP/SMIME or even Morse Code as long as it was completely standardized. Unfortunately, we picked multiple options. Some EHRs use XDR (a SOAP transaction) and some use SMTP/SMIME. Whenever standards have an "OR", all vendors must implement an "AND". XDR must be translated into SMTP/SMIME and SMTP/SMIME must be translated into XDR. The reality of Direct implementation has show us that this optionality provides a lot of plumbing challenges. Certificate and trust issues are still an ongoing project. Getting data from medical devices via Direct is challenging since devices tend to use heterogeneous transmission protocols. Finally, SMTP/SMIME was never designed for large payloads of multiple files, so sending datasets greater than 10 megabytes can be a struggle. The use of XDM for zipping files before they are sent is overly complex to use as part of a transport protocol.
Although Direct works, it is often not well integrated into the EHR workflow.
FHIR, as discussed in multiple recent posts, can help address these challenges and leverage the lessons learned. The FHIR concept is that every EHR will provide a standardized interface for the query, retrieval, and submission of specific data elements and documents using a web-based RESTful transport mechanism and OAuth security. This use case can easily support unique modules or �bolt on� application functionality to EHRs. It significantly simplifies the interfacing challenge, works for large payloads, and minimizes optionality. There are no multiple transport options, no certificates to manage, and the query/retrieve processes can occur behind the scenes, enabling smoother workflow.
FHIR can even be helpful as a transition strategy while Direct is still used for pushing payloads between EHR. If FHIR/REST/OAuth replaced the XDR/XDM options of Direct, that provides a glide path to the eventual end to end replacement of Direct with FHIR
Once FHIR is available, EHR vendors should design a user experience that follows the IEEE definition of interoperability - �the ability of a system or a product to work with other systems or products without special effort on the part of the customer. "
In summary, think of HL7 2.x as good enough for messages pushed between systems, Direct/CCDA as suitable but challenging for pushing XML documents between systems, and FHIR as a means to integrate multiple platforms via the use of application program interfaces that support the simple query/retreat/submission of data among applications.
FHIR will solve many of our interoperability challenges with appropriate support from EHR developers for clinically relevant workflow. We have to be careful not to oversell it, but for many use cases, FHIR is our best hope for the future.
Kamis, 15 Januari 2015
Unity Farm Journal - Third Week of January 2015
The third week of January is generally the coldest, most bitter time in the New England winter season. Temperatures dip to the single digits, snow/ice/winter mix cover the barnyard, and shoveling manure requires an ice chipper. Eggs laid overnight in the chicken or duck pen crack when they freeze solid. Every creature gets extra food to keep their internal furnaces stoked.
The ground is frozen and all the outbuildings are below freezing inside. Even the plants in the hoop house are need to be protected by row cover blankets. Nothing will germinate at below freezing temperatures.
Much of the work of the farm slows.
Now is the time of year that all that firewood preparation comes in handy. The house fires burn several hours a day, taking the chill off the evenings. The cold weather makes cutting hardwoods like maple more difficult. However, splitting is easier since the frozen wood tends to shatter.
There is one woodcutting opportunity that is only possible at this time of year - cutting fallen trees near the wetland. I would never do work in environmentally sensitive areas when water is flowing and the wetland would be disturbed. But at 7 degrees, all moist areas are a solid ice chunk and I can remove the broken branches and fallen trees that are likely to topple in an uncontrolled fashion, causing damage to surrounding flora and fauna.
Part of this woodlot maintenance includes taking down widow makers - dead trees that have fallen onto other trees and are hanging space. They are called widow makers for a reason. Do not try this at home! https://www.youtube.com/watch?v=eUQ1p2QPdxU After 20 years of experience with a chainsaw, I will take down selected widow makers that are at an angle/configuration likely to fall in a predictable way. Of all the things I do on the farm, taking down these partially fallen trees is the most dangerous activity. I leave the large ones and the complex ones to professional firms.
On particularly cold and stormy days in January, spending more time indoors to develop the spring planting schedule makes sense. Last weekend Kathy and I decided that in 2015, we�ll grow cranberry beans, beets, broccoli, carrots, cucumbers, japanese eggplant, mibuna greens, lettuce, pak choi, peas, daikon radishes, spinach, swiss chard, tomatoes, and turnips in the hoop house. We�ll have 3 major planting dates - March for root vegetables, April for the greens, and May for the cucumbers/tomatoes/peppers/eggplant that we�ll transplant from seeds started indoors in April. We�ll plant our outdoor squash beds in May. In June, our new permaculture plants - chestnut trees, pawpaw, and rice (yes, rice) will go into product. The rice planting is an experiment that will require me to do some engineering creating a rice paddy.
Here�s a handy germination/planting/harvesting guide we use for our planning. The 2015 hoop house plan is also pictured below.
The joy of winter in New England is that the Spring planting season is that much sweeter. It�s like hiking in subzero temperatures for 2 days and having your first hot meal. Food never tasted so good.
As every day passes on the farm, we build less and maintain more. After this planting season, we�ll have set into motion the trees, perennials, and permaculture ecosystem that can be handed off to the next generation when our time on this earth expires, 30 or 40 years from now.
The ground is frozen and all the outbuildings are below freezing inside. Even the plants in the hoop house are need to be protected by row cover blankets. Nothing will germinate at below freezing temperatures.
Much of the work of the farm slows.
Now is the time of year that all that firewood preparation comes in handy. The house fires burn several hours a day, taking the chill off the evenings. The cold weather makes cutting hardwoods like maple more difficult. However, splitting is easier since the frozen wood tends to shatter.
There is one woodcutting opportunity that is only possible at this time of year - cutting fallen trees near the wetland. I would never do work in environmentally sensitive areas when water is flowing and the wetland would be disturbed. But at 7 degrees, all moist areas are a solid ice chunk and I can remove the broken branches and fallen trees that are likely to topple in an uncontrolled fashion, causing damage to surrounding flora and fauna.
Part of this woodlot maintenance includes taking down widow makers - dead trees that have fallen onto other trees and are hanging space. They are called widow makers for a reason. Do not try this at home! https://www.youtube.com/watch?v=eUQ1p2QPdxU After 20 years of experience with a chainsaw, I will take down selected widow makers that are at an angle/configuration likely to fall in a predictable way. Of all the things I do on the farm, taking down these partially fallen trees is the most dangerous activity. I leave the large ones and the complex ones to professional firms.
On particularly cold and stormy days in January, spending more time indoors to develop the spring planting schedule makes sense. Last weekend Kathy and I decided that in 2015, we�ll grow cranberry beans, beets, broccoli, carrots, cucumbers, japanese eggplant, mibuna greens, lettuce, pak choi, peas, daikon radishes, spinach, swiss chard, tomatoes, and turnips in the hoop house. We�ll have 3 major planting dates - March for root vegetables, April for the greens, and May for the cucumbers/tomatoes/peppers/eggplant that we�ll transplant from seeds started indoors in April. We�ll plant our outdoor squash beds in May. In June, our new permaculture plants - chestnut trees, pawpaw, and rice (yes, rice) will go into product. The rice planting is an experiment that will require me to do some engineering creating a rice paddy.
Here�s a handy germination/planting/harvesting guide we use for our planning. The 2015 hoop house plan is also pictured below.
The joy of winter in New England is that the Spring planting season is that much sweeter. It�s like hiking in subzero temperatures for 2 days and having your first hot meal. Food never tasted so good.
As every day passes on the farm, we build less and maintain more. After this planting season, we�ll have set into motion the trees, perennials, and permaculture ecosystem that can be handed off to the next generation when our time on this earth expires, 30 or 40 years from now.
Kamis, 08 Januari 2015
Unity Farm Journal - Second Week of January 2015
It�s -6F this morning on the farm. We expect negative temperatures during the second and third week of January every year, so we have to prepare the animals, infrastructure, and equipment.
The alpacas and dogs have the benefit of a small oil-filled space heater in the barn which raises the internal temperature of the building about 10 degrees. Protected from the wind, rain, sleet, snow, and ice, the animals curl up together in hay covered stalls, sharing bodily warmth while minimizing heat loss due to convection, conduction, and radiation. See my previous post on staying warm in New England
The chickens and guineas have 4 flat panel heaters mounted on the ceiling and walls of the coop. The coop is dry and the floor is raised off the ground a foot. Between the heaters and the 80 birds roosting in the space, the temperatures are 20-30 degrees above the ambient air temperature
The ducks generally prefer to be outside, but their duck house has 1 flat panel heater and is protected from the wind. Today they are all inside their duck house.
The Japanese fountain in the moss garden is shut off - evening moving water freezes at -6F.
The equipment on the farm - the Terex tractor, the commercial mower, the wood splitter, the chainsaw, the blower, and the brush cutter have all been prepped for winter. I�ve added diesel or gas stabilizer as appropriate to each device and filled their tanks to 90% capacity in an effort to reduce condensation and frozen fuel lines. I�ve changed the oil in every device. I�ve cleaned and lubricated every control system. So far, so good, everything runs.
The humans have to wear multiple layers - a base layer for dryness, a mid layer for warmth and a shell layer for wind protection. Balaclavas, thick gloves, and insulated boots make me feel more like an alpinist than a farmer, but spending an hour in -6F requires that degree of protection. Remember, there is no such thing as bad weather, just poor clothing choices.
The root vegetables in the hoop house have all been harvested and the turnips/radishes/beets are stored in the relative warmth of a 35F walk in refrigerator. All the vegetable beds in the hoop house have thick row covers
Although some might prefer the warmer climates of the Southwest and Southeast this time of year, I relish the seasonal expectations of snow and cold in the winter followed by the gentle warmth of Spring.
The alpacas and dogs have the benefit of a small oil-filled space heater in the barn which raises the internal temperature of the building about 10 degrees. Protected from the wind, rain, sleet, snow, and ice, the animals curl up together in hay covered stalls, sharing bodily warmth while minimizing heat loss due to convection, conduction, and radiation. See my previous post on staying warm in New England
The chickens and guineas have 4 flat panel heaters mounted on the ceiling and walls of the coop. The coop is dry and the floor is raised off the ground a foot. Between the heaters and the 80 birds roosting in the space, the temperatures are 20-30 degrees above the ambient air temperature
The ducks generally prefer to be outside, but their duck house has 1 flat panel heater and is protected from the wind. Today they are all inside their duck house.
The Japanese fountain in the moss garden is shut off - evening moving water freezes at -6F.
The equipment on the farm - the Terex tractor, the commercial mower, the wood splitter, the chainsaw, the blower, and the brush cutter have all been prepped for winter. I�ve added diesel or gas stabilizer as appropriate to each device and filled their tanks to 90% capacity in an effort to reduce condensation and frozen fuel lines. I�ve changed the oil in every device. I�ve cleaned and lubricated every control system. So far, so good, everything runs.
The humans have to wear multiple layers - a base layer for dryness, a mid layer for warmth and a shell layer for wind protection. Balaclavas, thick gloves, and insulated boots make me feel more like an alpinist than a farmer, but spending an hour in -6F requires that degree of protection. Remember, there is no such thing as bad weather, just poor clothing choices.
The root vegetables in the hoop house have all been harvested and the turnips/radishes/beets are stored in the relative warmth of a 35F walk in refrigerator. All the vegetable beds in the hoop house have thick row covers
Although some might prefer the warmer climates of the Southwest and Southeast this time of year, I relish the seasonal expectations of snow and cold in the winter followed by the gentle warmth of Spring.
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