Meaningful Use and Certification Improvements

Today, HHS circulated the following important announcement:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Building Unity Farm - Preparing for Winter

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

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

Here's how it all works:

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

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

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

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

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

Let it snow!

Commanding Versus Leading

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

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

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

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

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

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

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

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

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

Building Unity Farm - Thanksgiving on the Farm

Thanksgiving is a time for family and friends to reflect on the past year, be grateful for the good things that happen every day, and consider the journey we're all on, which is hopefully headed in a positive direction.

On a farm, this day of thanks is very personal.    As with last year, the foods we prepared were either grown at Unity Farm or at a farm within one mile of our dining table.   There was one exception - the cranberries were from a bog on Cape Cod.

We boiled turnips and roasted root vegetables.   We picked mixed lettuce from the hoop house.   We baked pumpkin and apple pies with fruit picked from our orchard. We opened bottles of Unity Farm sparkling hard cider made this Fall in the cider house.  We made stuffing from chestnuts and oyster mushrooms, fresh picked from our mushroom farm.   Next year we'll have shitake to add to the table, but this winter the logs are still in their mushroom growing phase.

The alpaca got an extra helping of alfalfa mixed with molasses.  The dogs enjoyed a few fresh eggs.  The chickens, ducks and guinea fowl got fresh lettuce.

I've described life at Unity Farm as joyful chaos.  There are always chores to do.   There are no vacation days or weekends.   But somehow, I never feel that hauling hay, filling water buckets, turning compost, splitting logs and the constant movement needed to support the plants and animals constitutes work.   We spent the day as a family doing everything needed to support the community living on the farm.   My daughter split ash and black birch logs for the hearth.  I chainsawed fallen trees and branches from yesterday's storm (we had 40 mph winds and 3 inches of rain).  My wife watered our winter produce in the hoop house and planted new vegetables - the hoop house was 80F at midday while the outdoor temperature never rose past 32F.

The family spent the day together doing tasks that benefitted all.

Tomorrow, we have no shopping planned, just tasks that will further help us prepare for the heavy snows that are likely to start in a few weeks.  

This was my first Thanksgiving without my father, so we took time at dinner to pay tribute to those not present - my Father, Kathy's mother, and those who we've known in life who are no longer with us.

I hope you have a peaceful day and many things to be thankful for.   Although we all face many challenges, hopefully you still have a sense that the future will be even better than today.

Rethinking Certification

As stakeholders in payer, provider, and government communities debate the optimal timing of ICD10, Meaningful Use Stage 2, ACA, and HIPAA Omnibus rule deadlines, it's becoming increasingly clear that many hospitals which attested in 2011 and 2012 will not have their 2014 edition certified software installed, training completed, and workflow re-engineered in time for the Stage 2 attestation deadlines.

Now that we have experience with two stages of Meaningful Use, it's also clear that a three year cycle is needed to ensure safe, high value, well adopted, introduction of new IT functionality.

Part of the problem, as I've discussed previously, is that the certification criteria are overly burdensome and in many circumstances disconnected from the attestation criteria, requiring very prescriptive features that go beyond the intent of Policy Committee and Standards Committee.

How did this happen?  When Meaningful Use Stage 2 regulations were being written, ONC entered a "quiet period" in which smart people wrote regulatory language and certification scripts isolated from the rest of the world to ensure there was no bias introduced.   This was a "waterfall methodology" in which elaborate specifications and a long planning process was followed by an isolated development process resulting in a single huge deliverable with little opportunity to validate the result, pilot the components, or revise/improve the product after the fact.  The flaws in the Stage 2 certification scripts are an artifact of the regulatory process itself.

Healthcare.gov taught us that waterfall approaches are risky.    A better approach would be to create certification scripts using an "agile methodology".   Standards and scripts to test them could be developed outside the regulatory process, with iterative stakeholder feedback, testing of components, and rapid cycle improvement.   The regulatory process could point to the standards which would have accompanying implementation guides and test scripts.   There would be no "quiet period" or isolation in the development of certification scripts.    Such an approach would significantly reduce future certification burdens.

In addition to this, I recommend an even more radical redesign of certification.

We should maintain attestation as a demonstration of performance, but limit certification to rigorous standards adoption and interoperability, not prescriptive functionality.

What do I mean?

The Meaningful Use Workgroup believes decision support should be expanded in the future.   I agree.   Although they are now looking at outcomes that demonstrate the use of decision support, their initial work included recommendations for very prescriptive decision support certification criteria including:

Ability to track CDS triggers
Ability to flag preference-sensitive conditions and provide decision support materials for patients
Check for a maximum dose /weight based calculation
Use of structured SIG standards
Consume external CDS interventions
Use info in systems to support maintenance of lists

In effect, this tells vendors how to enhance clinical decision support features.

Let me use analogy.

Suppose that the government decided USB thumb drives are a good thing.   Not only would they specify a USB 3.0 standard, they would require it is black, rectangular, and weighs 2 ounces.    Such prescriptive requirements would stifle innovation since today's USB drives might be in the shape of a key or even mimic a sushi roll.

When evaluating the success of the US healthcare IT program, Congress tends to focus on interoperability - why are there gaps in DOD/VA data sharing or few seamless transitions of care among inpatient and outpatient facilities?

If certification focused entirely on interoperability, EHRs would be a bit more like USB drives.  They might be big or small, black or red, key shaped or sushi shaped.  However, they'll work with any device you plug them into.

I've spoken with many EHR vendors (to remain unnamed) and all have told me that they created software that will never be used by any clinician but was necessary to check the boxes of certification scripts that make no sense in real world workflows.

If certification required rigorous demonstration of outbound and inbound interoperability with no optionality in the standards (use this standard OR that standard), Congress will be happy, patients will be happy, and vendors will be happy.

Once we come up for air after ICD10, MU2, ACA, and HIPAA, I'll be watching any MU3 planning very closely to ensure we do not again make the same mistakes with certification scripts that are untested or too prescriptive.   Let's all focus on universal adoption of enhanced interoperability as a measure of success.

Building Unity Farm - Making the Perfect Cider

In North America, we think of apple cider as a non-alcoholic drink available for a few weeks in the Fall.   Before prohibition, most cider was fermented to 4-6% alcohol as a means of preserving it.  Cider was available from casks throughout the year.  John Adams drank a quart for breakfast every morning.   Puritan laws urged moderation and suggested no more than half a gallon of cider be consumed per day!

When I use the term cider, I mean fermented cider.

Over the past few years, there has been a resurgence of interest in craft ciders from such producers as Farnum Hill (Poverty Lane Orchards in Lebanon, NH), West County (Colrain, MA), and Julian (San Diego area)

Having tasted dozens of craft ciders, I know that creating the ideal Unity Farm cider will require significant experimentation.   I've read 5 books about traditional cider making and their collective advice is to balance a blend of sweet, sharp (tart), aromatic, and bitter (tannic) apples using this template

Sweet (30-60%)
Sharp (10-40%)
Aromatic (10-20%)
Bitter (5-20%)

The Unity Farm orchard yielded some apples this year, but not enough to press a batch of cider, so we purchased apples from local farms in Sherborn.

Last weekend we pressed 400 pounds of apples as follows

Sweet - Empire (1.5 bushels), Baldwin (1.5 bushels), Cortland (1 bushel), Spencer (.5 bushel), Macoun (.5 bushel)

Sharp - Stayman Winesap (1.5 bushels), Northern Spy (1 bushel), Granny Smith (.25 bushel)

Aromatic - McIntosh (1.5 bushels)

Bitter - although we wanted to add crab apples or Newtown Pippin, none were available

This mixture created 18.5 gallons of juice with a ph of 3.65 and a specific gravity of 1.055.  Using the template above, our distribution of apple types was

Sweet  54%
Sharp  30%
Aromatic 16%
Bitter 0%

I sterilized the cider with 50ppm of Potassium Metabisulfite (appropriate for a cider with a ph of 3.65) and let the sulfite decline for 48 hours before inoculating with Champagne yeast and yeast nutrients.    I used a 60 liter Spiedel fermenter.

The initial fermentation will take 2 weeks and then I will rack the cider and allow 2 additional weeks for the end of primary fermentation.   I'll assess the flavor and ph at that time and if necessary will encourage a secondary malolactic fermentation to reduce total acidity.

This batch will be still cider (not carbonated) so I will sulfite again and bottle into 22 ounce brown glass bottles.  I'm using an early 1900's cast iron bottle capper to ensure a good seal.

At Christmas time, I'll taste our sparkling and still cider experiments to gain a better understanding of the apple blending art.

We're looking forward to the output of our 33 apple trees in the next few years.    Using the sweet, sharp, aromatic, and bitter template we planted these trees in the Unity Farm orchard:

2 Empire (sweet)
  Braestar (sweet)
  Northern spy (sharp)
  Whitney Crab (bitter)
  Ben Davis (sweet)
  Winesap (sharp)
  Granny Smith (sharp)
  Cox Orange Pippin (sharp)
  Pink Lady (tart)
2 Red Delicious (sweet)
  Fuji (sweet)
  Macoun (sweet)
  Arkansas Black (bittersharp)
  MacIntosh (aromatic)
  Gala (sweet)
  Roxbury Russet (aromatic)
  Rome Beauty (sweet)
  Honeycrisp (sweet)
  Sheep nose (sweet)
  Cortland (sweet)
3 Kingston Black (bittersharp)
  Ashmead's Kernel (aromatic)
  Newtown Pippin (bitter)
  Golden Russet (aromatic)
2 Wickson's Apple (tart)
  Nehou Apple (bittersweet)
  Baldwin (sweet)
  Blacktwig (tart)

Most are heirloom cider apples from the UK and France.

To me the perfect cider is crisp, complex, and never cloying.   In a month, I'll have a better idea how close I've come.

Fine Tuning the National Healthcare IT Timeline

I've recently written about healthcare.gov and the lesson that going live too soon creates a very unpleasant memory.

As I work with healthcare leaders in Boston, in New England, and throughout the country, I'm seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.

People are working hard.   Priority setting is appropriate.   Funding is available.

The problem is that the scope is too big and the timeline is too short.

What are the risks?

Because of the complexity of the Meaningful Use stage 2 certification process, many stage 1 certified products have not yet been certified for stage 2.   Those that are stage 2 certified have only been recently introduced into the marketplace, making upgrades, training, testing, and full implementation before July 1, 2014 (the beginning of the last reporting period for hospitals which attested to stage 1 in 2011 and 2012) very challenging.   I believe that we could see hundreds of hospitals fail to attest to Meaningful Use stage 2 by the current deadline, despite their best efforts.

We learned from healthcare.gov that end to end testing with a full user load and complete data set is important to validate the robustness of an application.   ICD-10 go live for every provider and most payers (other than Workman's Comp) is 11 months away.    Does CMS have time for a full end to end test of all functionality with its trading partners?   I am concerned that not enough time is available.    Will most payers and providers be ready to process transactions on October 1, 2014?  Maybe.   Will new documentation systems, clinical documentation improvement applications, and computer assisted coding to ensure auditable linkage between the clinical record and the highly granular ICD-10 billing data be in place?  Doubtful.    Will RAC audits discover that not enough time was available for training, education, testing, innovation, and workflow redesign?  Certainly.    The risk of a premature ICD-10 go live will be the disruption of the entire healthcare revenue cycle in the US.   The consequences of a delay in enforcing ICD-10 use are minimal.

ONC federal advisory committees are taking testimony from multiple stakeholders regarding the technology and policy readiness of provisions in the HIPAA Omnibus rule such as the Accounting of Disclosures and private pay redaction requirements.    It's very clear that more time and more research is needed before these elements of the law can be enforced.

The Affordable Care Act has many provisions including a move from fee for service to reimbursement based on quality. Quality measures were to be automatically submitted using the QRDA standard.  On November 5, CMS backtracked and announced that they would not accept the QRDA formats and all reporting for January 2014 would revert back to a manual web upload process called GPRO.   It is clear that CMS is not ready to move forward with ACA implementation on the original planned timelines.

So what should we do to fine tune the national healthcare IT timeline?

Meaningful Use Stage 2 attestation timelines should be extended by 6 months to enable recently certified products to be fully implemented in a safe and thoughtful way.    90 day reporting periods for hospitals begin October 1, 2013 and for eligible professionals begin on January 1, 2014.  Attestation must be completed within one year.  Extending attestation to 18 months will give us time to implement new software upgrades properly.

ICD-10 enforcement deadlines should be extended by 6 months to enable additional testing and workflow redesign.  The October 1, 2014 deadline may work for some providers and payers. Transaction flow can begin if systems are functional.   However, a 6 month extension will enable providers and payers to revise and improve systems before a mandatory full cutover.   We need to do this to avoid another healthcare.gov situation.

The Accounting of Disclosures and private pay redaction aspects of the HIPAA Omnibus rule should be delayed until pilot implementations can be studied and lessons learned broadly shared, likely a year.

Affordable Care Act implementation should await for maturity in the tools needed to support care management and quality reporting, likely another year.

All of these projects can be done and are reasonable components of national efforts to improve quality, safety, and efficiency.

However, the well meaning people who devised the policy principles did not take into account the operational requirements to do all this work simultaneously.   We should keep moving forward on these goals, but need to adjust the pace.    We all want to finish the race and not collapse before the finish line.

Social Networking for Good

I've written about many aspects of social networking in the past such as

*Security risks and policy implications

*Support for research collaboration

*Applications in performance improvement

*Opportunities to reduce the provider documentation burden

One aspect I have not written about previously is the use of social networking for good such as fund raising for noble causes.

Just as I mentor 2-3 graduate students at a time, my wife has mentored fellow artists and supported them via Hatchfund

Although I've donated my time to various technology accelerators such as Rock Health, Tech Stars and Healthbox, I've not spent time on Kickstarter  or other crowd funding websites.

My wife told me tonight that she has made small contributions to worthwhile causes in the art, farming advocacy, and social cause areas.

Whether it's philanthropy, angel investing, or creating good karma, I find donation decisions to be very personal.    I've written many times that I want to make a difference and seeing tangible results on a small scale by using a social networking fundraising site seems more tangible than a donation to a large and anonymous organization.

Over the next year, I'll be working on creating my own social networking for good to fund innovation in healthcare IT.

In the meantime  I'll be paying more attention to crowd funding sites as I allocate my own contributions.

Building Unity Farm - The Powder House Keeper

One of the great benefits of owning a colonial era property is that you never know what you're going to find.

James Bullard was born in Sherborn on August 25, 1762 and died on June 30, 1828.

He's buried in our backyard.

As I've written about previously, the town of Sherborn stored its gunpowder on the Unity Farm property in the Powder house from 1800-1857. The Powder House was accessed via Powderhouse Lane, next to the Bullard Family home at 33 Main Street.   James Bullard was assigned the role of Powder House keeper, which was especially convenient since the Powder House was about 100 feet from his back door.

The Bullard Family home is now called the Sherborn Inn and the Powder House has been dismantled, although the foundation is still visible and accessible via Unity Farm's Marsh Trail.

James was married to Mary Harding on November 9, 1786.

On the day of their 227th wedding anniversary I was cutting wood on Unity Farm's Gate Path.   The late fall sun shone through the leafless forest and reflected off a piece of bluestone in the forest.   I looked closer and found that the light was coming from James Bullard's gravestone, near one of our old pasture walls.

As I looked around the grave I noticed an old cedar with something hanging on it.  Above the grave, an old wooden snow sled, silvered and shrinking with age, hung from a branch.   There's no brand, no label, and no clear attribution on the sled.     Was this James Bullard's "rosebud"?  Was his gravesite located on his favorite sledding hill on the land behind his 1700's home?

Mary Harding,  James' wife, died in 1796 at the age of 33 and is buried in the Plain Burial Ground in Sherborn.   James is buried on our farm under a mysterious gravestone in the woods, guarded by an old cedar supporting an ancient snow sled.

I'm not sure what it all means, but of all the Revolutionary War artifacts on Unity Farm, the grave of the Powder House keeper was not something I expected to find.

The November HIT Standards Committee

The November HIT Standards Committee focused on the current status of certification and attestation, readiness of standards for patient generated data, ONC S&I Framework progress, and the overall HITSC workplan.

Jacob Reider, Acting National Coordinator, joined us and offered his perspective on the work ahead as a physician, informatician and marathon runner.   Our goals include meaningful use, as well as many other future looking functions required by many stakeholders in industry, government, and academia.

We reviewed the themes of the meeting which importantly focused on the scope, timing, and resources we need to be successful.  Doing too much, too fast, with limited resources is not going to get us to the finish line.

We started the meeting with a Policy update from Jodi Daniel  including FDASIA, Joint Commission and safety efforts.   An important foundation to that discussion was presentation of the current state of certified technology adoption.

Next, Leslie Kelly Hall presented preliminary high level recommendations from the Consumer Technology Workgroup for the standards required to collect data from patients and devices as well as enable bidirectional care coordination and communication with providers.

Doug Fridsma presented an S&I Framework Update of projects funded by ONC and other government agencies.  I asked the Standards Committee to comment on the scope of work - should we recommend more or less S&I initiatives given available resources?   We recognized that many of these initiatives are funded outside of the Meaningful Use process, so priority setting is up to ONC and its paying customers.

Doug Fridsma also presented the Standards Committee workplan priorities as suggested  by HIT Standards Committee members.     Although we need to separate the "mediums" into those we do and those we don't, there was uniform consensus that a focus on image exchange, quality measurement, referral workflow, record locator services, and care plans makes great sense.

A very productive meeting.

Building Unity Farm - The Duck Pond

As I've written about recently, Fall has been a busy time at Unity Farm.  We completed our first harvest, pressed cider, picked mushrooms, planted winter vegetables, and cared for young animals.  

Although we have a year round stream running through the farm, we do not have a pond for our ducks, deer, raccoons, opossums, and other local fauna to access standing water during the winter.

This Fall we built a small pond near the barnyard.

In New England, we have very rocky soil, so we had no shortage of boulders for pond building.   Our mushroom farming work generated many spare logs.   All the building materials for a pond were already on the Unity Farm property.

We needed two things to succeed - someone to provide pond building expertise and someone who could move/carve/assemble rocks.   Together, John Novak and Sean Cudmore created the duck pond pictured above.

The engineering includes a bog area that acts as natural filter, many plants to provide oxygenation, and a pattern of circulation that keeps the surface free of debris.

The ducks are 6 weeks old and soon will be given the run of the barnyard.   Our experience with ducks thus far is that they live for water.   Our 10 ducks drink (or groom with) about 3 gallons of water per day.  They have a talent for turning any dry soil into mud.   They're not shy about spending the day in their outdoor pen no matter what the weather.   I'm convinced the pond will be paradise for them.

Maintaining a pond in winter will be a learning experience for me.   As one of the few unfrozen water sources for nearly a square mile, the Unity Farm duck pond will be very popular.

Quality Measurement 2.0

I've written several posts about the frustrating aspects of Meaningful Use Stage 2 Certification.   The Clinical Quality Measures (CQMs) are certainly one of problem spots, using standards that are not yet mature, and requiring computing of numerators and denominators that are not based on data collected as part of clinical care workflow.

There is a chasm between quality measurement expectations and EHR workflow realities causing pain to all the stakeholders - providers, government, and payers.   Quality measures are often based on data that can only be gathered via manual chart abstraction or prompting clinicians for esoteric data elements by interrupting documentation.

How do we fix CQMs?

1.  Realign quality measurement entity expectations by limiting calculations (call it the CQM developers palette) to data which are likely to exist in EHRs.   Recently, Yale created a consensus document, identifying data elements that are consistently populated and of sufficient reliability to serve in measure computations.   This is a good start.

2.  Add data elements to the EHRs over time and ensure that structured data input fields use value sets from the Value Set Authority Center (VSAC) at NLM.    The National Library of Medicine keeps a Meaningful Use data element catalog that is likely to expand in future stages of Meaningful Use.

3.   Greatly reduce the number of CQMs required by private and public entities to a consistent, manageable number.  That way we can focus on ensuring integrity of data elements used in quality measures.

This approach will create a “healthy tension.”   If HHS restricts measure developers from using an infinite number of data elements,  measure developers will express concern that available technology is limiting quality measurement.  If measure developers continue to include data that does not exist in the EHR, then developers will create burdensome add-on data entry screens to prompt providers for extra information just for the sake of CQM.

A few years ago, Jacob Reider (now the Acting National Coordinator) created these slides that illustrate how to cross the Quality Measurement chasm - modify expectations of quality measurement developers, while also enhancing EHRs with value sets from the VSAC and continuing to develop standards that support quality measurement (such as FHIR), optimizing workflow and usability.

As I've said before, I will do everything in my power to support Jacob Reider, ONC and "polishing" of Meaningful Use Stage 2.

Revising CQMs is likely to be a high priority of the HIT Standards Committee over the next year.    Watch for that discussion at the November 13 HIT Standards Committee meeting.

Dispatch from London

I'm in London for 48 hours, working with a group of international experts to define telehealth, care management, and big data opportunities for the UK, Europe, Australia, and US.

During the afternoon break I had a remarkable experience.

Unity Farm apples (40+ heirloom varietals) produce a crisp, well-balanced fermented cider that includes sweet, tart, aromatic, and astringent components.

Kathy, my wife, searched the web for the best cider pub in London and asked me to stop by so I could compare Unity Farm cider making with traditional farmhouse ciders from the UK.

The Cider Tap, a remarkable place, is, by good karma, 100 yards from my hotel in Euston Square.

Professor Justin Beilby, Executive Dean of the Faculty of Health Sciences at the University of Adelaide, and I  tasted six still and four sparking ciders, fresh from the cask.

Still:
1.  Severn Perry (made from crushed pears) - 6.3% alcohol, aromatic, dry, with a subtle pear flavor.

2.  Sandford Bumbleberry - 4% alcohol, sweet with a mixture of herbs and berries.    It reminded me of a traditional spiced mead - a metheglin.

3.  Bleangawney - 6% alcohol, dry, with an almost lime-like flavor.

4.   Upper House Farm Oak Barrel aged - 6.5% alcohol, medium/sweet with a clean, crisp flavor.   This was my favorite still cider and a style that I've tried to replicate at Unity Farm.

5.   Severn Farmhouse - 6.2% alcohol, medium, a classic full bodied english farmhouse cider

6.  Burrow Hill Alf n Alf - 6.0% alcohol  with a very complex taste that leads me to think it is half dry cider/half medium cider.


Sparkling:
1. Aspalls Harry Sparrow  - 4.6% alcohol, dry, crisp and clean.  This was my favorite sparking cider, a true scrumpy

2. Lilley's Stargazer -  5% alcohol, medium/sweet, with a great apple flavor

3. Sheppy's Oakwood - 4.8% alcohol, medium/dry without any overtones of oak, despite the name

4. Somerset draught - 5.5% alcohol, medium, well balanced and complex

The proprietress of the Cider Tap explained that the still ciders change weekly, with new fresh products produced in small quantities from local farms.

Tasting living, complex, handcrafted ciders made with centuries of experience was the highlight of my trip.    I only wish we had the local cider tradition close to Boston.    I guess it is up to Unity Farm to bring handcrafted ciders to the Metrowest!

Lessons Learned from the Health Insurance Exchange Launch

CIOs face many pressures - increase scope, reduce timelines, trim budgets.     After nearly 20 years as a CIO, I've learned a great deal about project success factors.

When faced with go live pressures, I tell my staff the following:

"If you go live months late when you're ready, no one will ever remember.

If you go live on time, when you're not ready, no one will ever forget."

I have hundreds of live clinical applications.    Does anyone remember their go live date?  Nope.

Were there delays in go live dates?  Many.

With even the best people, best planning, and appropriate budgets, large, complex projects encounter issues imposed by external factors (new regulations, competing unplanned events, requirements changes) that cannot be predicated during initial project scheduling.

It helps no one - the users, the business owners, or the IT department to slavishly adhere to a deadline when the project is not ready to go live.

I work on federal advisory committees in the Obama administration and truly believe in the goals of many administration programs - Meaningful Use, HIPAA Omnibus rule, and Affordable Care Act.

However, we've seen that in the interest of accelerating change, deadlines have been imposed that do not allow for sufficient testing, piloting and cultural change.  The result is that haste makes waste.

As I've written in my blog many times, ICD-10 will become a crisis for the Obama administration.   Payers and providers will not be ready by October 1, 2014.   Documentation systems and clinician billing process changes will not be mature enough to support a successful go live.   More time is needed.    My experience with IT crises is that you can survive one at a time, but a succession of problems creates a pattern that users and oversight bodies will no longer tolerate.   I hope the premature go live of the Health Insurance Exchange results in a review of ICD-10 go live dates.

Meaningful Use Stage 2 attestation criteria are good.   The certification scripts need very significant revision.   How did this happen?   They were created in a rush to adhere to an artificial deadline, not reviewed by the federal advisory committees, and not piloted tested/revised.     New regulation is needed fix them and that will take time.   Again, the lessons of the Health Insurance Exchange should cause us to extend Meaningful Use Stage 2 deadlines by a year, deferring future stages of Meaningful Use until we have consolidated our gains and understood our successes/failures with current stages.

The Office of Civil Rights is an important watchdog of patient privacy.   We all believe respecting patient privacy is one of our most sacred responsibilities.   However, at times government auditors have enforced policy for which the technology and infrastructure of the country was not ready.    Yesterday I received an email from Harvard Medical School noting that the laptop encryption software installed a few years ago was deemed too error prone and too hard to support so it would be retired.   Luckily in 2013, encryption is natively supported in current releases of Mac OSX, iOS, Android, and Windows.   The industry is ready to support robust device encryption now.    However, enforcement/breach penalties related to encryption on mobile devices started years ago when products were as stable as the Health Insurance Exchange.   We should have aligned enforcement with product maturity in the marketplace.   Similarly the HIPAA Omnibus Rule contains provisions like the self-pay redaction requirement that no hospital has figured out how to support.  However, enforcement is starting now.

Do we a see a pattern here?   Policies are good.   Policymakers are well meaning.  Timelines are set in such a way that none of these activities - Health Insurance Exchange, ICD-10, Meaningful Use Stage 2, or HIPAA Omnibus Rule have enough time for testing, piloting, and cultural change.

As I've written about previous in my post the Toad and the Snake, I'm not yet at that time in my life when I resist change or innovation.   I'm simply an IT leader and physician in the trenches who knows that 9 women cannot create a baby in a month.   There is a minimum gestation period for IT projects and our policymakers should learn from the lessons of the Health Insurance Exchange and re-calibrate the timelines shown in the graphic above so that everyone is successful.

Building Unity Farm - Fall Hoop House Planting

It's Fall in New England and the weather is turning cold.  Nights are in the 30's and days are in the 50's and 60's.   All the ferns in the forest are brown and most of the insects are gone.   On the farm, the apples are harvested, cider made, mushrooms dried, paddocks/pastures readied for winter, and the pace of harvest-related food preservation projects is slowing down.

We now turn our attention to Fall and Winter plantings.  Our 48x21 foot hoop house heats to 80 degrees F during the day by trapping solar energy under a 6 millimeter roof of UV resistant plastic sheeting.  We use barn fans to circulate air and hand cranked rollers to open the sides and prevent overheating.    The roof has a "gothic" cathedral shape which sheds snow and resists wind.

Over the summer, we built fifteen 4x8x1 foot raised beds and a gardening bench.   We brought water and electricity to the hoop house via a 200 foot trench from the house.   We placed a foot deep foundation of alpaca manure under each raised bed and now we're filling the beds with compost, moss, and perlite http://en.wikipedia.org/wiki/Perlite

In our first 2 beds we planted 200 bulbs of garlic, which will overwinter and produce new bulbs in the spring.   We've grown garlic for many years and enjoy bulbs of oven roasted garlic brushed with olive oil.

In our second 2 beds we planted romaine and oak leaf lettuces.   The heat of the hoop house should enable us to pick fresh greens every day during the winter.

In our remaining beds, we'll plant additional lettuces, kale, spinach, chard and other cold tolerant plants, keeping our kitchen and our barnyard stocked with fresh greens.   The ducks and the alpaca really enjoy a fresh head of romaine.   For the ducks, we chop the lettuce and mix it with water, creating a soup which they can easily slurp.

As the days shorten, we'll have less light to work in the hoop house, so I'll add 2 pendant galvanized barn lights http://www.barnlightelectric.com/pendant-lighting/barn-pendant-lights/the-original-stem-mount-pendant.html which will enable us to pick fresh salad greens in the evening after the work day.

It's our goal to become increasingly self-reliant over the next year as well as sell many of our products - honey, mushrooms, apples, blueberries, and vegetables at local farmers markets.   Although we've been farmers for a year, this will be our first winter with a hoop house, so I'm sure there will be many lessons learned growing vegetables as the snow begins to fall.

Reflections on My Trip to Asia

For 12 days, I served as guest professor in China, Japan and Taiwan, giving lectures, running meetings, and joining my colleagues for ceremonial meals.    In many ways, all three countries are trying to solve the same basic technology and policy challenges, but there are subtle differences.

China - China has a single payer system with universal, nationally funded healthcare in state operated hospitals and clinics.  Privately funded, entrepreneurial ventures  including high-end hospitals and clinics are emerging for those who want to purchase concierge care.   This article nicely summarizes the economic issues.

During this visit I had the opportunity to meet with Vice Minister of Health for China, as well as several hospital leaders, and informatics professionals.   Here's what I learned, although I will qualify my impressions with the fact that China is a large and diverse country and my visit was limited to Beijing, Hangzhou, and Shanghai.

There are over 500 vendors of EHR products and no market leader.   Many applications are home built or created by small, local companies which address the specific workflow needs of a single healthcare facility.    There is not a specific national healthcare IT policy, but there is recognition of the need for national interoperability standards and an incentive to use them.    Something like a certification program and meaningful use program may evolve.    There are many proprietary approaches to interoperability currently in use, and HL7 CDA is seen as a possible candidate for summary exchange.   Vocabularies such as SNOMED-CT, ICD9 or 10, and LOINC are not yet deployed but there is an understanding of the need for terminology services and an eagerness to work with US companies proving such services.  There are  pilots of healthcare information exchange, generally using a central repository model.   I asked an audience of 1000 people if they had ever used a PHR, and not a single hand was raised.   There is a desire to engage patients and families but no products in the marketplace yet.

The challenges faced by China include a population of 1.35 billion people, environmental concerns (air/water/land), an aging population, a significant migration of citizens from rural to city life,  and an increase in cancer/birth defects/respiratory diseases as a side of effect of rapid industrialization.

I look forward to next steps, which I hope include interoperability policy planning at the national level.  I've forwarded several US policy documents to the Chinese government and remain eager to work on Meaningful Use for 1.3 billion people and 20,000 hospitals.

Japan - Japan has broad healthcare coverage with a mixture of universal insurance and self pay.  This article nicely summarizes the economic issues.

There are a few large companies providing EHRs in China - Fujitsu, Mitsubishi, and NEC.  Hospital IT is frequently outsourced to such companies.   EHRs are typically client server architectures.   The web has not been widely embraced for EHRs, PHRs, or HIEs because of privacy concerns, but a few cloud computing pilots have been successful including an EHR for first responders in Fukushima.    There have been pilots of data sharing such as the Dolphin project in Kyoto and planning for PHR implementation.  

The challenges faced by Japan are an aging society, declining birth rate (1.4), lack of coordination of care because patients have access to any hospital/urgent care/clinician office on demand, creating a fractured record, and privacy policy that makes interoperability difficult.   Standards are emerging and there is an understanding of the need to use summary formats like CDA and controlled vocabularies.     A national policy requiring interoperability standards and encouraging data sharing with patient consent would significantly enhance quality, safety, and efficiency in Japan.

The government of Japan has recently changed and I'm told Mr. Abe will embrace innovation in healthcare IT as part of his economic recovery package.   Just as with China, I'm eager to help with a certification and meaningful use program, serving the 126 million citizens of Japan.

Taiwan - Taiwan has universal healthcare coverage with a mixture of universal insurance and self pay.  This article nicely summarizes the economic issues.

As with China, there are many small companies selling EHRs to local hospitals and clinician offices.  There's a long tradition of self-built systems as well.

Also, like China and Japan, most EHRs are client server, with little use of the web.

Privacy concerns restrict remote access, but I found the Taiwanese much more willing to embrace the internet and offer support for mobile devices, restricting information flows only to international locations because of privacy laws.

The hospitals I visited in Taiwan were high volume - 10,000 outpatients a day.  They implemented industrial process automation to help manage patient flow, laboratory specimen labeling, and medication dispensing.   I was impressed by their degree of EHR and ancillary system support.    Health Information Exchange and Personal Health Records are not widely used but there is a recognition of their importance for care coordination,

The challenges faced by Taiwan are an aging society, declining birth rate (.9), and ‘doctor shopping’ – patients visiting numerous practitioners simultaneously because of easy access to care at any facility without a primary care gatekeeper, creating a fractured medical record.

I look forward to further collaboration with my colleagues in Taiwan, helping create interoperability policy and technology to serve 23 million people.

In 12 days, I took 15 flights and worked long days to spend nearly 200 hours with government, academic and industry leaders.   I learned more than I taught.   Each country has its own unique history, culture and people.   However, the challenges of healthcare IT are very similar all over the world and the evolution that is taking place in our lifetime will ensure that Asia moves closer to the goal of  electronic health records for every citizen.

Losing the Popularity Battle, but Winning the Career War

CIOs are typically not very popular and are not known for their charismatic leadership i.e.

How do you distinguish an introverted CIO from an extroverted CIO?

An introverted CIO stares at his shoes.   An extroverted CIO stares at your shoes.

In the past, I've been able to achieve reasonable levels of popularity through rapid innovation and responsive agile application development, often delivering discretionary projects to individual departments.

As I navigate FY14, creating project plans that allocate resources and time, it's clear that I cannot deliver any discretionary projects.   If the Main Thing about leadership is To Keep The Main Thing The Main Thing (Stephen Covey) then I have no choice to but to keep IS resources focused on the Federal regulatory agenda that has been prescribed for FY14 and nothing more.

Now that I'm back from China/Japan/Taiwan, I will accelerate my efforts to communicate with stakeholders at all levels that the Federal government has set the strategy for healthcare IT departments in FY14 and as unpleasant as it sounds, IT management and healthcare stakeholders really have no flexibility to prioritize departmental projects.    Here's what I mean:

ICD10 - this federal requirement is pass/fail and involves the entire inpatient/outpatient revenue cycle.   Every piece of software, workflow, and process needs to modified.    It will cost the country billions, have limited benefits, and should be considered high risk, given the coordination needed among payer/provider organizations.   It's bigger than Y2K for healthcare and has a firm October 1, 2014 deadline that no one in government is willing to change.    Assume ICD10 will consume a majority of your IT resources for the next year.

Meaningful Use Stage 2 - this federal requirement is focused on stimulus in the short term, but penalty avoidance in the long term.   Hospital margins throughout the country are slipping, so it's very hard to turn down millions in Medicare/Medicaid stimulus.    ICD10 trumps Meaningful Use work, but hospital management really expects IT departments to deliver Stage 2 Certified software for everyone to use.   Eligible professionals who have already attested to stage 1 are looking to IT departments to provided updated  software so they can attest and claim the remainder of their $44,000 stimulus.    Meaningful Use Stage 2 has a 2014 deadline for hospitals and clinicians who attested to Stage 1 in 2011.

HIPAA Omnibus Rule/Compliance and Audits -  not a day goes by without a new audit by someone - OCR, OIG, DPH, internal, CMS.   I've heard that some IT departments are hiring full time staff just to respond to audits.  As with ICD10, these audits have limited benefit and consume resources that would have been applied to innovation in the past.   However, the work must be done.

ACA - The Affordable Care Act has required many new IT applications - health insurance exchanges, health information exchanges, quality registries, care management systems, and business intelligence infrastructure.  The Affordable Care Act required work is likely to improve efficiency and value in American healthcare.   However, the work displaces departmental priorities by consuming resources that might have been applied to local workflow enhancement projects.

Business imperatives with deadlines that cannot be missed - Healthcare reform has spawned a flurry of mergers and acquisitions that include fixed IT deadlines such as opening a building, extending networks, installing phone systems, merging clinical data, and expanding email coverage.  Although these are beneficial, the effort to support mergers and acquisitions takes resources away from optimizing local workflow and infrastructure.

What is the implication for CIOs?   Spreading a message that ICD10, MU2, HIPAA/Audits, ACA, and mergers have consumed all available IT resources for the next year is not going to be popular.   I truly expect many stakeholders to acknowledge that these priorities are reasonable as long as their departmental needs are also met.   The needs of the many are good as long as they don't outweigh the needs of the few.   Unfortunately, the answer for the next year needs to be "not now" if institutional survival is the main thing.

So over the next few months, I expect my waning popularity to wane even further.   I will lose the popularity battle.   However, when the regulatory mandates are done and the institution's longevity is assured, my career will be intact.   Losing the popularity battle but winning the career war for the benefit of the institution sounds like right long term strategy but certainly will require strength of will, a thick skin, and constant communication.

Building Unity Farm - The Poultry Grows Up

Last week I described our first year as farmers.   Just as we've grown, our animals have grown.

We started with 13 chicken chicks.   One was eaten by a hawk (Silver) and one died of egg impaction (Sunny).   The remaining 11 are happy and healthy, finishing their molt and preparing for winter

We started with 22 guinea fowl chicks.  11 have been eaten by predators because they have stayed out overnight sitting on nests or explored places they should not (fox dens, fisher cat habitat etc.).   However, we hatched 100 guinea fowl in August and kept 20 for ourselves.   They're now 8 weeks old and just about ready to leave the coop.   One alpha male (Mojo) was clearly very busy because 17 of the new guineas look just like him.

We received 10 ducks just 3 weeks ago and they've grown remarkably.  They enjoy eating a water soaked romaine lettuce and often stand in the bowl.   They live in a duck pen and spend the night in the duck house where it is warm.   Ducks don't care about wetness, so rain is not a motivator to go inside.    In another few weeks we'll let the ducks out to run around the property.  

Raising poultry is a remarkable experience.   All the chickens have distinct personalities and mannerisms.   There is definitely a pecking order.

Guineas are truly amazing to watch as they run around our 15 acres in search of ticks, worms, and other insects to eat.   They're excellent fliers and serve as a great alarm system, squawking whenever predators come close.  Their only downside is that are not skilled at survival in New England.   I'm sure that staying outside at night works in West Africa, but in the forests of New England, coyotes, foxes, raccoons, fisher cats, and weasels want nothing more than to eat Guinea fowl.

Ducks are remarkable.   They grow fast, live for water, and have distinct temperaments.  Some of ducks are calm, some of our ducks are nervous.  When we let the Indian Runner ducks out to circulate the property, it will be fascinating to see how they react to our wetlands.

At present we have 52 birds heading into the winter.  Hopefully all will survive until Spring.

Attestation verses Certification for HISPs

Of all the Meaningful Use Stage 2 questions I'm asked by vendors, HISPs, and providers, many involve confusion between certification and attestation.

As I've written about several times, the certification criteria are so extensive, often in unnecessary and confusing ways, that few vendors have been able to get through them.   Certification criteria exceed attestation criteria in many scripts.

I was recently asked about transition of care data exchange using Direct and the need for message delivery notification (MDN).   Micky Tripathi wrote the following excellent analysis, the bottom-line of which is that MDN is a narrow certification criteria, not an attestation requirement.   In the future, I think certification must be simplified to include the bare minimum necessary to support attestation.     Many people on the Standards Committee feel the same way and we'll support whatever polishing strategy ONC deems appropriate.

Micky wrote:

"1)  Organizations with self-developed systems may depend on a HISP as part of their certification, but organizations with vendor-based EHRs will not
a.   Although organizations with self-developed systems may chose to use the HISP as part of their alternative certification, most organizations will rely on their EHR vendor's complete certification
b.   For example, for Beth Israel Deaconess Medical Center certification, the HISP, acting as modular certified technology, needs to generate MDNs in response to incoming messages.
c.   For everyone else, the HISP does NOT need to generate any type of MDNs.  Sending providers only need to have reasonable assurance that messages sent via the HISP have been delivered to the intended recipients.

2)      There are three requirements that are relevant here:  the transitions of care attestation requirement, the technology certification for receiving messages, and the technology certification for creating/transmitting messages:
a.       The Meaningful Use Stage 2 transitions of care attestation requirement is that “the summary of care record must be received by the provider to whom the sending provider is referring or transferring the patient” (see page 4 of the measure)
b.      2014 Edition certification requires that an EHR be able to receive a Direct-compliant message and send an MDN for successfully received message (see page 5 of the NIST test script)
c.       2014 Edition certification requires that an EHR be able to transmit a Direct-compliant message to a Direct address recipient.  There is no MDN requirement on the transmission certification.  (NIST test script).

3)      The MDN requirement is SOLELY a certification requirement (it is NOT an attestation requirement) and it applies only to the requirements regarding receiving messages.  There is no certification requirement for MDN in transmission transactions.  There is no attestation requirement for MDNs (or any other technical means) to demonstrate assurance of receipt of transmitted transitions of care.
a.     While attestation does require that the intended recipient actually receive the message, there are no requirements on what type of assurance the sending provider must have in order to meet the Meaningful Use transitions of care measure.  Indeed, the ONC commissioned white paper on the topic of assurance states that:  “It is up to the Certified EHR Technology vendor to determine how to assist its customers and provide them with assurance that transmissions have reached their intended recipients.  This assurance could include a presumption of success on the provider’s part of subsequent transmissions if they have reasonable certainty that initial transmissions were successful.”  (see page 2 of the white paper)

4)      The MDN issue thus applies only to organizations that are using alternative certification and using the HISP as relied upon software because they need to be able to meet the “receive” and “create/transmit” criteria.  It does NOT apply to users who are using off-the-shelf Certified EHR Technology to transmit Direct messages over the HISP.
a.      Any other organization with off-the-shelf Certified EHR Technology which wants to use the HISP for transitions of care transmission does NOT need the HISP to be certified
b.      Their own Certified EHR Technology will generate a Direct-compliant message and pass it to the HISP for delivery
c.       The sender will have met their transitions of care requirement at this point as long as they have reasonable assurance that the HISP delivered the message to its intended recipient
d.      This assurance could be provided by MDNs delivered back from the receiving EHRs, but it does not have to be, and indeed, since recipients are not required to be Meaningful Use compliant, many recipients won’t be able to generate an MDN anyway
e.      In any case, it is NOT a HISP responsibility to generate and transmit MDNs back to the sending EHRs (except in the case where the HISP is acting as relied upon software for alternative certification)

5)      Some organizations may want the HISP to be certified for their attestation purposes.  For the purposes of attestation, the HISP will be certified ONLY for “generate/transmit” and NOT for “receive”, and thus it has no obligation to create MDNs
a.       In order for the HISP to receive modular certification for “receive”, it would have to be able to display CCDA documents, accurately match patients, and consume structured information for medication, problems, and medication allergies.  That would require that the HISP to include EHR features beyond the scope of HISP operations.
b.      Any organization that would like to attest with the HISP could thus only use the HISP for the “generate/transmit” requirement.

6)      Regardless of whether the HISP is used as just a conduit (#4) or as a certified module for transmission (#5), the HISP does need to provide some type of assurance of delivery back to the senders
a.       The current plan for the Massachusetts State HISP is to send back MDNs to provide assurance of delivery, which is ideal – however, it is NOT required
b.      The HISP could assure delivery by contract such as a service level agreement
c.      And/or the HISP could make available transaction audit records back to senders periodically or on-demand"

Dispatch From a Mysterious Island

Whenever I travel on business, I try to take a few hours to explore the road less traveled.   Whether that's climbing Mt. Fuji, hiking the Aonach Eagach ridge in Scotland, or crossing the Baltic Sea in a kayak, there's always an adventure to be found.

During my current Asia trip, I sought the help of several friends in Japan to arrange the trains, planes, and boats that would bring me to the shores of Yakushima, Japan's first World Heritage site, to explore the island's cloud forest and volcanoes.   Some of my colleagues who've heard about Yakushima, call it The Mysterious Island after the Jules Verne novel of the same name.

If I were to design the perfect Mysterious Island, here are the characteristics it would have:

1.   The approach should be difficult and ideally involve a small plane flying through miles of cloud cover with no visibility.    Check, did that.

2.   Ideally, crossing an active volcano should be involved.   Check, did that.

3.   The forest should be ancient, filled with giant trees over 5000 years old.   Check, Yakushima is filled with Yaku-sugi, cedar trees that are thousands of years old with circumferences exceeding 30 feet

4.   Make it wet so that the entire forest is covered with moss and waterfalls.   Check, Yakushima has the highest rainfall in the world, over 30 feet per year.

5.  Put it in the track of many typhoons to make staying there exciting.  I just flew from the island into Typhoon Wipha - the photo below shows the swirling vortex of the storm creating a strange split level sky.  My hiking clothes are saturated despite total body Gore-tex.

6.  Make it dark and misty with 6000 foot cloud-covered peaks topped with snow in the winter.   Check, here are a few shots of the cloud forest I hiked.

7.   Fill it with unusual animals, insects, and birds that are found nowhere else in the world, including miniature deer and walking sticks that look like a cross between a centipede and spider.  Check.   It also has leeches, giant hornets, enormous spiders, venomous centipedes and poisonous snakes

8.  Add monkeys, it must have monkeys.  Check.  Yakushima has its own species of Macaque Monkey

9.  Give the plants an almost human look with long finger-like roots. Add vines and exotic flowers.  Check.

10.  Add forest spirits.   Admittedly, that only happened in the movie inspired by Yakushima, the Miyazaki anime called Princess Mononoke.   Almost check.

My visit to the Mysterious Island included 20 miles of hiking/climbing with a 6000 foot elevation gain including scrambling over moss-covered rocks during a typhoon.  I stayed in a wonderful place called  Wa no Cottage Sen-no-ie  handcrafted of cedar.  I highly recommend staying there if you visit.  The people who run it are remarkable and speak English.

I think a visit to Yakushima qualifies as the road less traveled.   Priceless.

Building Unity Farm - Reflections on our First Year as Farmers

While I'm traveling in Asia, my wife Kathy is running the farm, ensuring that all our animals are healthy, our last few harvest duties are done, and our preparations for winter have begun.

Before I left, I did everything possible to minimize her tasks.   I installed heating panels in the duck house so that she could move the duck babies from the brooder to the outside world.   I harvested mushrooms from all our fruiting logs.  I added yeast and nutrients to our fermenting apple cider.  I secured all our gates, cleaned the barn, and finished moving all our building materials into the hoop house.

Thinking about the past year, we're well on our way to a productive, self-sustaining farm.  Here's a status report

Mushrooms - we've gathered our first 25 pounds of oyster mushrooms from 144 poplar logs stacked in two forest locations.   We've finished inoculating Shitake spawn into 165 oak logs housed in the shade house plus 110 logs in the forest.   We've inoculated 10 logs with Lion's Mane.   Next year we should have commercial quantities of mushrooms to sell.

Bees - Our 8 hives built up their honey stores all summer , despite our harvesting of 160 ounces.   Our queens are healthy and the bees are disease free as we head into winter. Given the strength of our hives, we should substantial honey harvests next year.

Apples - we've placed an order for additional trees to add to the orchard in 2014
3 Kingston Black
1 Ashmead's Kernel
1 Newtown Pippin
1 Golden Russet
2 Wickson's Apple
1 Nehou
1 Baldwin
1 Blacktwig

bringing our total to 40 apple trees.   This year we crushed 250 pounds of apples and fermented enough juice for 75 bottles of still and sparkling hard cider.  Above is a look as the fermentation in progress.   In five years, we'll have nearly 7000 pounds of apples per year for eating, selling, and cider making.

Blueberries/Raspberries/Elderberries - our planting of 180 high bush/150 low bush blueberries and placement of permanent bird netting is complete.   The blueberries already yielded a few pounds, but we should have hundreds of pounds within a few years. The raspberries and elderberries should begin producing next year.

Alpaca/llama - Our 11 alpaca and 1 llama are in perfect health.  Two are pregnant.   They understand the routine of monthly "herd health" checkups and trust us to handle them with respect and gentleness.  The barn is fully stocked for winter with all the hay we need to last until next hay season.

Poultry - our 11 chickens, 31 guinea fowl (11 adults and 20 babies), and 10 ducks are completely adapted to their surroundings and the routine of going into their coops at night for protection.    Pecking orders are established, and our poultry community lives in harmony, eating wild foods throughout our 15 acres every day.   Our baby ducks are shown below.

Dogs - Our two Great Pyrenees are now fully grown and protect all our animals.  Admittedly since they weight nearly 200 pounds together, running with them (I weigh 165) can be an adventure

Hoophouse and Vegetable Garden - Our year round indoor and outdoor vegetable gardens are now complete along with watering, fertilizing, and harvesting infrastructure.   We'll grow lettuce, kale, and spinach all winter long.  Next spring we'll plant enough crops to supply half our food.

It's been a great first year on the farm and the daily activities caring for the animals/plants has become so integral to our lives that travel away (like my current responsibilities in Asia) seems completely out of balance.