The September HIT Council meeting

Yesterday, the Massachusetts HIT Council met to review progress on the state HIE.   Here is the presentation we used.

Important highlights include:
*41 organizations are now connected to the state HIE
*We've done nearly 1.5 million transactions
*We've decided how to create a trust fabric with other Health Information Service Providers (HISPs).   We will support authentication by exchanging trust anchors and signing HISP to HISP agreements. We will support authorization through the use of a white list that includes those organizations which have signed our Massachusetts participation agreement
*In late October/early November we will demonstrate Phase 2 of our HIE functionality - a statewide master patient index and consent registry which supports "pull" transactions such as patients arriving at Emergency Departments, enabling us to gather medical information from multiple institutions.

To me, we're near the tipping point of interoperability.   The standards, the ACO imperative to share data, and the motivation of meaningful use Stage 2 have created the perfect storm for providers, payers, and patients to share data.

Building Unity Farm - The Cider House Tools

The orchard at Unity Farm has 36 trees, of which 24 are heritage apple varieties.   Since each tree will produce 5 bushels (a bushel is 42 pounds), we'll have 120 bushels (over 5000 pounds of apples per year) when the trees reach maturity.    Of course we'll eat, sauce, jelly and produce various apple products from them, but my favorite way to enjoy fresh apples in the Fall is to make cider.

One bushel yields about 3 gallons of cider, so we could make up to 360 gallons.

Cider can be frozen and kept for a year but even with pasteurization (which changes the flavor), unfrozen cider will not keep more than a few weeks.

The easy answer to preserving cider is to make traditional fermented hard cider.

Here's how we'll do it.

In the orchard, we have a cider house, pictured above.  All our orchard harvesting and honey processing tools are kept clean and dry in that building.  We have a 36 liter cider press and grinder which can produce about 9 gallons of juice per pressing, pictured below

We'll test our apples for flavor, acidity, tannin content, sweetness, and bitterness then choose a combination of apples that will make a balanced cider.  Our hand cranked fruit grinder sites on top of the press and we'll fill the pressing basket with approximately 2 bushels of ground apples.    We'll apply pressure via the hand cranked ratcheting screen and gather the juice a gallon at a time.  I prefer a two stage fermentation with racking of juice from the spent yeast for a clearer final product.   I have two fermenters made from food grade HDPE plastic, which is unbreakable and easy to clean.   I've had good luck in the past with Champagne yeast  and will make a starter culture the night before pressing.   Once inoculating, I'll let fermentation proceed naturally in the 60 degree outdoor temperatures that are typical in late September/early October.  When the initial fermentation is done, I'll siphon the juice from one fermenter to another and let it ferment another week.  

I prefer my ciders to be very dry, so I do not plan on adding any sweetener before bottling.   I will likely make a few bottles of sparkling cider as well, adding a bit of sugar solution then bottling in swing top containers.   After a few months the cider will mellow and carbonate, ready to ring in the new year if all goes well.

Since hard cider has been an American home brew tradition for hundreds of years, the laws regulating production and distribution are simpler than wine.   In a few years, I hope invite friends and colleagues to bring their growlers to fill with Unity Farm cider, hand made with our cider house tools.

The August HIT Standards Committee

On August 22nd, the HIT Standards Committee held it's 50th meeting.   We began this milestone meeting by thinking Farzad Mostashari for his national service via a formal proclamation highlighting his accomplishments.  Richly deserved.

Liz Johnson and Carol Bean then presented an Implementation Workgroup update, describing the findings from the Implementation/Usability hearing on July 23rd and presenting test scenarios which will hopefully replace/augment the existing certification scripts.  

They key idea is that scenarios would mirror real clinical workflow from registration to evaluation to transition of care, using the same data and building upon each incremental data entry step.   Such an approach not only reduces the burden of certification but also ensures the EHR is more than disconnected functions built to satisfy disconnect certification criteria.   In effect, scenarios demonstrate the usability of integrated functionality.   I'm also hoping that these scenarios remove some of the certification demonstrations are not part of attestation workflow.    In my view, certification should only include the minimum functionality clinicians need to support attestation and nothing more.   As I posted in my blog yesterday, creating too many regulatory demands can stifle innovation.

Next, Dixie Baker presented an NwHIN Power Team Update finalizing the recommendations for future transport standards.   She reviewed the work of Blue Button Plus, HL7's Fast Healthcare Interoperability Resources (FHIR), and the S&I Framework's RESTful Health Exchange (RHEx) to identify industry trends and emerging standards.   The team concluded that combination of RESTful transport supported by a specific implementation guide and supplemented with OAuth2/OpenID for authentication holds great promise as a simpler to implement approach than currently required in Meaningful Use.   The team also concluded that FHIR has many appealing simplifications as a content standard.      The Standards Committee recommended pilots and once we have real world experience with the combination of RHEx/OAuth2/OpenID/FHIR we should seriously consider their incorporating into future stages of Meaningful Use.

Finally, Lauren Thompson and Jodi Daniel provided an ONC update, highlighting work to accelerate HIE, patient/family engagement, and safety.

At our September meeting we'll present initial recommendations for image exchange and early thinking about how to represent advance directives in EHRs.

Making progress.

What Keeps Me Up at Night - Fall 2013

As Summer draws to a close, I have returned to my usual blogging schedule!

Now that Labor Day has come and gone,  I've thought about the months ahead and the major challenges I'll face.

1.  Mergers and Acquisitions

Healthcare in the US is not a system of care, it's a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers.    As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create "systemness" through mergers, acquisitions, and affiliations.   The workflow to support systemness may require different IT approaches than we've used in the past.   We've been successful  to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via  "magic button" viewing and state HIE summary exchange.   Interfacing is great for many purposes.   Integration is better for others, such as enterprise appointment scheduling and care management.   Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2.  Regulatory uncertainty

Will ICD10 proceed on the October 1, 2014 timeline?  All indications in Washington are that deadlines will not be changed.    Yet, I'm concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation.    Will all aspects of the new HIPAA Omnibus rule be enforced including the "self pay" provision which restricts information flow to payers?  Hospitals nationwide are not sure how to comply with the new requirements.   Will Meaningful Use Stage 2 proceed on the current aggressive timeline?  Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1.   With Farzad Mostashari's departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3.  Meaningful Use Stage 2 challenges

Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine.   One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems.   I have 25 developers and a part time analyst available for the task.   I've read every script and there are numerous areas in certification which go beyond the functionality needed for attestation.    Many EHR vendors have described their certification burden to me.    I am hopeful that ONC re-examines the certification process and does two things - removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.  

4.  Maintaining agility in a resource constrained world

At the same time we have ICD10 (a multi-million dollar burden), Meaningful Use Stage 2 (a multi-million dollar burden), the Affordable Care Act (a multi-million dollar burden), the HIPAA Omnibus Rule (a multi-million dollar burden), and increasing compliance oversight (a multi-million dollar burden), reimbursement is declining, sequestration is squeezing budgets, and fee for service medicine is transitioning to risk based contracts.    The ability of provider organizations to maintain operations while implementing all the new regulatory requirements in parallel is straining healthcare operations to their limits.   Safety, quality, and efficiency innovations are no longer possible because regulatory requirements  have consumed all available resources.

5.  Leading in real time

My organizations maintain hundreds of applications and thousands of devices with 99.9% reliability.    Rather than praise us for our diligence, the average user in 2013 wants to now why we are not meeting their needs .1% of the time.  When I do not respond to a request in 5 minutes or less, I'm asked if something is wrong.   Leadership in the era of Twitter is expected to be all seeing, all knowing, and omnipresent.   Strategic thinking, planning, and consensus building is challenging in a real time world that expects instant gratification.

I do not mean to sound pessimistic in any way.   All of these challenges can be conquered.   For nearly 20 years, I've led an IT organization that has continuously delivered miracles with 1.9% of the operating budget.   I am ready for the challenges ahead but wonder if mergers/acquisitions, regulatory uncertainty, MU2 certification challenges, resource constraints, and real time demands will create a set of constraints that are impossible to optimize.    Given that my role is to understand all the constraints and find a path forward, it's the Kobayashi Maru scenario that keeps me awake at night .   As Captain Kirk figured out, if the rules of the game make it impossible to win, the only answer is to change the game.    I remain the eternal optimist and am convinced that if we all work as hard as we can, the rules of the game will be changed so that we can succeed.

Unity Farm Keets (Guinea Fowl chicks) Available Now

Our Guineas have been remarkably fertile this Summer and we'll have 100 babies available for purchase.   They're $4 each.

Guineas are tick eaters and will rid your yard of many undesirable insects.   You will need a coop to keep them safe from predators at night.

Our first hatching of 20 is extremely healthy and we'll have another 30 hatching this weekend.

Although chicks are shipped in general, our experience is that the process is extremely stressful for them.    Anyone wanting guineas should contact us at khalamka@gmail.com for New England (Sherborn, MA) pick-up.  Here are the details:

Straight Run (M/F) Hatched 8/20/2013
Pearl Gray (standard dark color)
Pearl Gray Pied (white chest)

Colors possible (Pearl Gray, Pearl Gray Pied, White, Lavender and Lavender Pied)
2nd Hatch on 9/3/2012
3rd Hatch (last for the year) on 9/18/2013
All will be well feathered by the time cold weather arrives

$4 each or 10/$30

Building Unity Farm - Preserving History

Since Sherborn's founding in 1652, the land of Unity Farm has been adjacent to the town center.  In the past, the property has been a dairy, sheep paddocks, and part of a much larger farm.   As I've cut trails through the property I've uncovered old tools, old timbers, and numerous rock walls.

Along the Unity Farm Marsh trail are two particularly interesting sights - the Sherborn Powder House and the Old Dug Well/Windmill.

The Powder House
The Powder House for Sherborn was built by the town in 1800 so that gun powder could be removed from the public meetinghouse where it had been stored, much to the relief of concerned citizens.  James Bullard was appointed keeper and the building was constructed in a meadow overlooking the lane behind his house at 33 North Main Street.  Although the actual building was demolished in 1857, the site of the Powder House is on our property.    The circular foundation is still in place and the rocks used to build up the walls are lying adjacent to the foundation.   An ash tree has grown up inside the former building.   Today, railroad tracks cross Powder House Lane in Sherborn, so the Powder House is no longer publicly accessible.      I've cleared the area, connected it to our trails and will be adding National Forest Service-like signage to it soon.

The Old Dug Well
About 100 feet south from the Powder House is an old, hand dug, brick-lined well.   When I first found it, the well was filled with 5 feet of mud, wood debris and midden.   What do I mean by midden?   As I began to excavate the well, I found 10 old milk crates, hundreds of pounds of old unmilled lumber, rusted iron tools, and an old menu board, pictured below.    Although fragments of the menu board are missing, it appears to announce "Great Steaks" like the "Powder House Tenderloin", Sirloin, Round, etc.  The lettering appears to be from the early 1900's.   I've asked Historical Society members about the well and steak sign.  Their only guess is that it might have been related to the old train station on Powder House Lane (no longer there) that used to be the major transportation hub in Sherborn.

Next to the well, an old windmill (blades shown above) provided the energy to pump the well water uphill to sheep grazing meadows.  

Since the well has now been restored to be a fully functional water source, I built a cover for it from 6x6 and 3x5 lumber.   We do not want wandering deer (or wayward teens) to fall into the well.   Our Great Pyrenees may not be as communicative as Lassie if Timmy falls into it.

Building Unity Farm - The Guinea Fowl are Born

It's August in New England and although everyone in healthcare IT is consumed by Meaningful Use stage 2, ICD10, ACA, the HIPAA Omnibus Rule, and various compliance initiatives, it's also the time we try to take a few hours off before the busy Fall.   Although I'm not taking any vacation this year, I have reduced my writing schedule (hence fewer blog posts this month) and spent more time at Unity Farm.

This week our first 20 guinea fowl hatched and the keets (the name for young guinea fowl) are running around the brooder, eating, drinking, chirping, and sleeping.

Here's how we did it.

Guinea fowl are terrible parents.  They lay eggs in a community pile and one female incubates them all.   Unfortunately, they tend to lay in the forest near fox dens, fisher cat habitat, and coyote trails.   We've lost several females this Summer but luckily found the nests and gathered the eggs before they were too chilled to be viable.

We placed them incubators at 100F and 50% humidity.   The gestation period of a guinea is 26-28 days.

Automated egg turners slowly moved the eggs for the first 23 days.  Then we laid them flat in the incubator, making it easy for the chicks to peck through the shells.

On day 25, one of the larger eggs started to roll, crack, and chirp.    A few hours later, a piebald keet was born  (Keets come in pearl black, white, grey, and piebald).

On day 26 and 27, the rest of the eggs popped like popcorn with little keets running around the incubator.   About an hour after birth we moved them to the brooder, a larger space kept at 100F with ample food and water.

Three of the 23 eggs did not hatch (hence the expression don't count your chickens before they're hatched), which is typical for game birds.   After verifying that there were no signs of movement, I carefully opened the 3 unhatched eggs and found that all  had developmental issues and an early demise.

The 20 keets that hatched are amazingly active, large, and robust.   Our batch of keets last year arrived in the mail and we had quite a lot of attrition.  There are definite advantages to hatching your own poultry.

Animal husbandry is hard and Guinea Fowl can be challenging, as illustrated by this great article in the Atlantic.

At 4 weeks, we'll move the guineas to the coop, but keep them from free ranging until 12 weeks.  We find that 2 months in the coop gives the guineas a chance to mature and be able to defend themselves agains predators.  It also firmly establishes the coop as their home and they'll return to sleep there every night as adults after a day in the forest.

We've gathered nearly 100 guinea eggs from forest nests and all are in our incubators.  Although we can keep 50 or so in our coop and sheds, we'll sell the others to local farms.   Given the significant increase in tick-borne disease across the country. we believe that guinea fowl, nature's most efficient tick eater, will be very popular with homeowners in the rural areas west of Boston.  

Guineas have become such a regular part of our lives that I cannot imagine a day without them.  Looking out my home office window, I expect to see the guineas running by on their quest for food and camaraderie.