December 31, 2015

Unity Farm Journal - 5th week of December 2015

It’s been a great first week with pigs.  Hazel Marie, the 100 pound two year old pot belly, experienced her first snowfall.   Although I’m building all season dutch doors for the pig barn, they are not finished yet, so I installed a piece of plywood in the doorway, cutting out a piece so that she can easily access the entry ramp.     The end result has been a warm, dry, snow-free pig barn filled with fresh hay, a heater, and a blanket.   Hazel arranges a deep pile of hay then burrows into the blanket.   Every morning we play find the pig - she’s invisible curled up in her nest.


I mentioned last week that we would be getting Hazel a companion.    Meet Tofu, a three month old pot belly pig that weighs 20 pounds.   Don’t be fooled by his diminutive appearance - he’ll outweigh hazel soon.     He’s very outgoing and enjoys the same fresh fruits, vegetables, and grains as Hazel.   They ate dinner together separated by a square of dog fencing in the pig barn we’ll use to keep them apart until they adjust to each other.


The freezing rain, sleet, and melting snow have covered the farm in a sheet of ice.  Every surface is slick and challenging to navigate.   Walking the dogs is an extreme sport - imagine 250 pounds of dogs pulling 170 pounds of me on a sheet of glass covered with butter.    I call it “boot skiing”.    So far, no orthopedic injuries.

All the families have left post Christmas and life has returned to normal.   What is normal on Unity Farm?  Wake up at dawn, dig a 40 foot trench for a ground wire, install electric fence cable with the help of a pig, and  connect the power supply to a new circuit in the pig barn.    Hazel and Tofu now have a hot wire on the top of their paddock fence to keep out coyotes.

This weekend, I’ll finish up the pig barn door and continue my work on tree house railings and stairs.   We’ll have temperatures in the 40’s without snow this weekend, making outdoor carpentry possible.

Of course, when the weather turns cold and snowy, there is always indoor work to do on my winter semester Umass coursework - Backyard Homesteading.    This week we created maps of our homesteads and did a water analysis.    Here’s my finished presentation of the material.

Next week will be a caloric analysis - what do we need to grow to feed ourselves based on daily requirements for protein, carbohydrates, and fats?   Today we grow about half our food and with each passing year we get better at raising crops on a predictable schedule.

Next week I’ll post our farm goals for 2016.

Happy New Year!

December 30, 2015

The 2016 Standards Advisory


ONC recently released the 2016 Standards Advisory.  I think this document is more important than Meaningful Use or Certification in accelerating interoperability.  Why?

Many view Meaningful Use as no longer aligned with the work we need to do for population health, care management, and alternative payment models.   The more aligned activities - the Affordable Care Act (ACA), Medicare Access & CHIP Reauthorization Act of 2015 (MACRA),  and private payer risk-based payment models  - require health information exchange for care coordination and quality/financial benchmarking.   These programs create a business need for interoperability affecting a large percentage of an organization’s income versus Meaningful Use which at this point is a penalty program creating a small reduction in an organization’s income.  When there is a business need and enabling technology, interoperability happens.   The Standards Advisory gives developers, providers, and patients a list of enabling technologies, documenting their level of maturity and adoption for a given purpose.   The marketplace can decide which standards are good enough, what risks to take on promising evolving standards, and which standards to retire as technology progresses.

Standards making is all about reduction of optionality - constraining the methods to represent information and transport it.   To me, the Standards Advisory is exactly what government should do - convene experts to determine which standards are appropriate for purpose - then let industry decide what to implement based on the business need.

The process used to create and refine the Standards Advisory is a good one, in part based on this paper by Dixie Baker,

Importantly, the Standards Advisory is a continuous process, not one that sets a standard in the concrete of regulation/legislation that is hard to change.  The advisory process is agile and likely to be more transparent than the regulation making done behind closed doors.   The list of best available standards can include some standards that are not yet ready for production since the document is just a roadmap to what is available at a given time, not a regulation.  

In the past, many HIT Standards Committee experts have advised ONC not to include standards like HPD (a provider directory standard) because it is not suitable for purpose in an internet connected, cloud-based, mobile friendly EHR world.   Standards Committee members prefer the FHIR-based directory services that are being piloted in the Argonaut project (www.argonautproject.org).    With the Standards Advisory, the debate of HPD over FHIR becomes moot since both can be listed as available standards along with descriptions of their functionality, maturity and adoption.   The industry can then decide which is more fit for purpose.

As I’ve written about previously, it is my hope that CMS eliminates the Meaningful Use Stage 3 penalty, uses pay for performance incentives based on outcomes as part of MACRA to replace Meaningful Use goals, and that certification for stage 3 will rarely be done because it is a purely voluntary program.   Redirecting our focus to customer requirements rather than regulatory compliance will accelerate innovation.     The combination of outcomes-based performance incentives and the yearly publication of a standards advisory is a great path for the future.

December 28, 2015

Make Health Care Great Again

Click here to view: Reading of the Donald J. Trump children's book by Jimmy Kimmel
We don’t win anymore in health care. After repeatedly drilling in our heads that America’s sick care system is a disaster, that those who care for the sick are incompetent and stupid, and that the sick themselves are losers, Meaningful Use was advertised as the means by which technology will make health care great again. The program has been in place for 5 years and the great promise of Meaningful Use is just around the same corner it was back in 2011. The only measurable changes from the pre Meaningful Use era are the billions of dollars subtracted from our treasury and the minutes subtracted from our time with our doctors, balanced only by the expenses added to our medical bills and the misery added to physicians’ professional lives.

Meaningful Use, a metastasizing web of mandates, regulations, exclusions, incentives and penalties, is conveniently defined in the abstract as a set of indisputably wholesome aspirational goals for EHR software and its users, which stands in stark contrast to the barrage of bad news flooding every health related publication, every single day. Health care in America used to be the best in the world, but now our health care is crippled. Meaningful Use of EHR technology will improve quality, safety, efficiency, care coordination, and public and population health. It will engage patients and families, and it will ensure privacy and security for personal health information. With Meaningful Use leading the way, health care will be winning so much that your head will be spinning. You won’t believe how much we’ll be winning.

Be afraid, be very afraid

Bombastic? Laughable? Easily dismissible by educated people? Not so fast. According to Dr. David Blumenthal, president of the Commonwealth Fund, and former National Coordinator for Health IT, “we probably have the worst primary care system in the world”. Yes, worst system in the whole wide world, worse than Niger, Malawi and Somalia. Probably. According to a hobbyist “study” that extrapolates its “results” from a handful of other studies based on an admittedly inaccurate tool intended for different purposes, 440,000 people are killed in hospitals due to preventable errors each year – “that's the equivalent of nearly 10 jumbo jets crashing every week”. Or, with a little more math, half of all hospital deaths, and one in six US deaths, are due to negligent homicide perpetrated by psychopathic doctors and nurses.

How is that for buffoonery? I suspect that the beautiful minds appalled at populist or outright racist fear mongering rhetoric claiming that thousands of Muslims were dancing on rooftops on 9/11 in New Jersey, have zero problems with self-servingly stating that “hospitals are killing off the equivalent of the entire population of Atlanta one year, Miami the next, then moving to Oakland, and on and on”, based on equally valid he-said-she-said evidence. Both virulent strains of outlandish demagoguery are insisting that they, and only they, can keep us safe from things that go bump in the night. Supersizing the ghoulies and ghosties and long-leggedy beasties makes us more likely to relinquish control of our lives to those who might deliver us from terror.

The Meaningful Use program rests on a narrative where medicine is witchcraft, our doctors are murderers, our hospitals are cesspools teeming with death, our citizens are Lemmings unable to wipe their noses, and the machines of the illuminati are our only salvation. When the premise of an action is delusional, one cannot expect the outcomes to be anything but.

Smoke and mirrors

When you read “studies” advertising that Meaningful Use increased the rates of mammography by 90% in three months, you should assume that the only thing that was increased is the rate of ticking boxes for stuff that was not documented before, and practically no material changes have occurred. When you feel vindicated by the 99% rate of patients given a clinical summary after each visit, keep in mind that the vast majority of those summaries were posted to a portal that nobody uses, or just fake-printed to PDF, and the few actually given out were dutifully tossed in the recyclable trash bin. When you read about the billions of dollars in tax money successfully spent on Meaningful Use, you should understand that this is just the tip of the iceberg, and the indirect costs to each and single one of us are larger by orders of magnitude.

For most of us simpleton believers, who mistook fiery demagogues for brave-hearted visionaries, the disappointment is a throbbing daily humiliation, manifesting itself in polite low-energy petitions to powerful bureaucrats to take pity on us and roll back some of the most onerous aspects of the program. There are signs indicative of some forthcoming acts of mercy, but those are as disingenuous as the original false narrative of Meaningful Use. After five years of Meaningful Use of EHR technology, the initial hope has failed to translate into promised change. Or has it?

From its inception, the Meaningful Use program had two sets of requirements. One set defines what EHR vendors must build to stay in business, and another set specifies what doctors and hospitals must do to collect gratuity payments from Medicare. Over time these requirements sets began to diverge. Once clinicians became conditioned to compulsively collect data, overt reporting is being replaced with covert extraction through the backend (i.e. application programming interfaces, or APIs). The Certified EHR Technology mandated by the program was never intended to extend abilities of clinicians as much as it was designed to generate standardized measures of their performance. Administrators and regulators cannot control an industry from afar without incessant measurement and the power to reward and punish individual practitioners. Meaningful Use is designed to enable remote control of medicine, its doctors and the people they serve.

We are not alone

Back in 2001 our rulers identified another field where America was losing big time. Education was a disaster, a huge mess with rampant disparities and across the board low quality. Like health care, education of small children is an ideal place for intervention if your aim is to control populations and increase the value derived from each person. With overwhelming bi-partisan support the ruling class passed the No Child Left Behind Act, mandating that all children are above average by 2014. An avalanche of funding for computers, measurements of schools and teachers and incessant standardized testing of students descended upon our schools. For the last fifteen years, schools were engaged in life and death accountability games of reward and punishment, and our children became merely biometric indicators for school and teacher performance assessments.

As 2014 came and went, with many children still stubbornly below average, with multitudes of teachers still burnt out, and education morphing into a misnomer for the standardized testing doomsday machine consuming all but the rich and privileged, the federal government took a step back and passed the Every Student Succeeds Act of 2015. Leaving aside the downright idiotic terminology used for naming acts of Congress, the new legislation is reluctantly beginning a process to diminish federal control of schools. Considering the cumulative damage to our education system, perpetrated by toxic bureaucratic ineptitude which is  crowding out the ability of real educators to address real problems, this halfhearted attempt may very well be too little too late.

Failure is not inevitable

I don’t know about you, but I am getting tired of having to live up to Winston Churchill’s image of America. We don’t always have to try everything else before we do the right thing. We shouldn’t have to wait fifteen years before declaring that in retrospect Meaningful Use was meaningless. We know now that it is. Removing a few reporting requirements for physicians, while beefing up patient scoring measures, is not enough. Playing with reporting periods at the last minute and granting ad-hoc exclusions to make people shut up, is not enough either. Randomly linking physician fees to Meaningful Use EHRs may be enough, but it’s beyond disgusting.  The Meaningful Use program must end. Plain and simple. And most importantly, the underhanded EHR certification schemes must be halted immediately.

Standardization, quantification, computerization, gamification, engagement, and infantilization of the populace in general, do not produce better educated or healthier citizens. Education reform has failed us on a grandiose scale. Health care reform, to which Meaningful Use is foundational, is based on the same failed concepts as education reform. It will also fail in due course and spectacularly so. It is actually failing as we speak and with the exception of elite institutions, which are benefiting financially from as much health care reform as can possibly be inflicted on the rest of us, we all know it’s failing badly. 2016 presents the perfect opportunity to demonstrate to the entrenched perpetrators that in America accountability is a two way street, and value is a freely defined personal concept.

American health care has been hijacked by very bad people, and it’s time for us to quit being sad little losers who just sit there and bitch. It’s time to take our health care back and it’s high time to deliver to those horrible people the thorough schlonging they so richly deserve. It’s time to make American health care great again.

In 2016, resolve to go out and vote. Vote in the primaries, vote in local and general elections, ignore the propaganda, educate yourself and as old Harry Truman advised us all, vote for yourself, for your own interest, for the welfare of the United States, and for the welfare of the world.

December 24, 2015

Unity Farm Journal - Fourth Week of December 2015

Last week I mentioned the Unity Farm Christmas list.

I’ve been an avid student of permaculture - creating an ecologically sustainable farm that keeps everything in balance.    I harvest thousands of pounds of vegetables per year but compost  the imperfect vegetables..   There must be a better way.

Hazel Marie is the answer.


Welcome the latest addition to Unity Farm, our 100 pound pot bellied pig.  We rescued her (as we have done with several of our farm animals) from a home which abandoned her to the MSPCA/Nevins Farm.   She is a delight with a constantly wagging tail, boundless energy and curiosity about the world around her.    I plan to walk her around the property on a harness and she’ll live in one of our pastures in the newly finished pig barn.   Last weekend I added heated water buckets, a panel heater (pig safe) and interior LED lighting.



My daughter, Lara Marie, approves of Hazel Marie as our official surplus vegetable consumer.   We will find Hazel Marie a piggy companion once we have more experience with pigs.    We really like Patches, a 200 pound male recently surrendered to Nevins Farm, but he will grow to 800 pounds.   We’re not sure we can handle that much pig.   Kathy’s Christmas gift to me is Hazel.

Kathy has had significant joint pain and neuropathy since her chemotherapy.   Hauling hundreds of pounds of bee hives around our 15 acres has been difficult for her.   Although I’m 53 and relatively fit, I find hauling hundreds of pounds of lumber, tools, mulch, vegetables, and firewood around the farm to be fatiguing too.    The Terex front loader is great for rocks, mushroom logs, snow, manure, and wood chips, but it’s not something you drive casually for transportation.    The answer - a golf cart utility vehicle.   My Christmas gift to Kathy is a Yamaha Adventurer One, a golf cart with a 300 pound hauling capacity for her to to drive around the property and do all the things she wants to do, regardless of any physical limitations.

What about stocking stuffers?   I asked Kathy for Havahart vole traps so I can reduce the damage to the hoop house vegetables during the winter when small furry creatures take refuge in the vegetable beds.    I also asked for a labeler/gluer that enables me to put formal labels on all our cider, beer and mead bottles.

Finally, for the family, I finishing the build out of the treehouse I started in the summer.   Although a platform without railings 15 feet in the air sounds great to me, it’s not appealing to everyone.    Here’s the progress thus far turning the platform into a finished 12x12x12 foot cube, suspended in air but accessible via a 3 foot staircase protected by railings.    In Spring I’ll add a roof.   I think the family will like it.


Although Christmas day will be 60 degrees, we’ll soon have the chill of January, so I’ve tucked the vegetables into their raised beds with row covers.   Here’s what the hoop house looks like now.


The farm is looking festive as we approach the holidays.    The cider house has wreath under the barn light, as does the barn, the tool shed, and the house entrance.


The inlaws, outlaws, and all our close family will be at the farm for the next few days.    We’ll revel in the warmth of the season, each other’s company, and gentle sounds of geese, pigs, dogs, alpaca, ducks, chickens, guinea fowl, and cats all living in harmony at Unity Farm.

And to all a good night!

December 23, 2015

My 2016 Predictions for HIT

As the year ends and we archive the accomplishments and challenges of 2015, it’s time to think about the year ahead.  Will innovative products and services be social, mobile, analytics, and cloud (SMAC)?  Will wearables take off?  Will clinicians be replaced by Watson?   Here are my predictions

1.  Population Health will finally be defined and implemented -  Recently I asked a number of clinicians to define population health.   Although no one could define it, they were sure that their current EHR did not provide the desired functionality.    To me, population health tools in 2016 will automatically aggregate data from multiple provider, payer and patient sources then create lists of patients with care gaps to be closed.    This article in Harvard Business Review illustrates some of the functionality we’ve built at BIDMC in anticipation of 2016 needs.

2.  Security threats will increase - Two weeks ago, the Attorney General for National Security from the Department of Justice visited Boston to meet with a group of CIOs and CISOs, describing the escalating number and sophistication of cybersecurity attacks.   He concluded that if a device is internet connected, it will be compromised.   At BIDMC, we will continue to invest millions in security technology, rewrite many of our policies and invest in continuous security education for all our staff.   Despite our best efforts, I cannot promise a breach-free year in 2016.

3.  The workflow of EHRs will be re-defined.   In 12 minutes, can a clinician enter 200 structured data elements, manage 140 quality measures, be empathic, never commit malpractice and make eye contact with the patient?   Nope, it’s impossible.   This Wall Street Journal piece illustrates the problem

The EHR must evolve from a fraud-prevention tool in a fee for service world to a team-based wellness tool supporting alternative payment models.    I’ve told CMS that the ideal EHR will be a combination of Wikipedia (group authored notes) and Facebook (you’ll have a wall of health related events)

4.  Email will gradually be replaced by groupware - Managing daily email is a burden with minimal rewards.  Facebook has announced Facebook for Work to provide enhanced communication among teams, supported by enterprise grade security.    I receive over 1500 emails a day and might declare email amnesty in 2016 (an out of office message declaring email to be an ineffective communication medium and suggesting that I will never respond)

5.  Market forces will be more potent than regulation - Meaningful Use has accomplished its goals.   MU is dead, long live MU.   We need to move away from prescriptive regulations so complex that no one understands them.  Instead, we need pay for performance based on outcomes, giving providers and industry the freedom to achieve these outcomes using whatever technology they feel appropriate.

6.  Apps will layer on top of transactional systems empowered by FHIR - Epic, Cerner, Meditech, Athena, and eClinicalWorks are all fine companies.  However, will the next great app be authored by their staff?   I’m guessing a better approach is crowdsourcing among clinicians that will result in value-added apps that connect to underlying EHRs via the protocols suggested in the Argonaut Project (FHIR/OAuth/REST).   One of our clinicians has already authored a vendor neutral DICOM viewer for images, a patient controlled telehealth app for connecting home devices, and a secure clinical photography upload that bypasses the iPhone camera roll.    That’s the future.

7.  Infrastructure will be increasingly commoditized - In 2016, I will be moving select applications to Amazon and Google.  They can offer a better/stronger/faster/cheaper service because of their scale than I can do myself.    They are willing sign Business Associate Agreements.   Why do I want the risk of operating multiple data centers myself for commodity services like web hosting?

8.  Less functionality with greater usability will shape purchasing decisions -  Recently a clinician told me that EHR A has half the features of EHR B, therefore EHR A is twice as good!   Remember Wordstar and Word Perfect?  Try authoring an outline in the most modern version of Microsoft Office.    Prepare to have your work destroyed by feature bloat in Office.   Clinicians want usability, speed, and simplicity, not more features.

9.  The role of the CIO will evolve from provisioner/tech expert to service procurer and governance runner - From 1996-2001 I wrote many of the foundational applications of Beth Israel Deaconess.   My education at Stanford, UCSF, UC Berkeley, Harvard, and MIT enabled me to innovate rapidly as a clinician, domain expert, and engineer.  Today I do not write code and my role is to empower/enable talented people around me with funding, protected time, and political will.    The CIO of 2016 will increasingly be an orchestra conductor and not a technology expert.

10.  The healthcare industry will realize that IT investments must rise for organizations to meet customer expectations, survive bundled payment reimbursement methods, and create decision support/big data wisdom - I often tell my stakeholders that scope, time and resources are tightly coupled.   You cannot increase scope without increasing time or resources.    As more automation is deemed critical for the needs of the business, IT budgets will be increased as a strategic imperative.   There will be a tension - the CFO will want to increase capital budgets (purchasing of stuff) while the CIO will want to increase operating budget (purchasing of services and subscriptions to cloud functionality)

That’s my top 10 list.   And no, Watson, will not replace clinicians, although Natural Language Processing is a technology to watch in 2016.   Other companies will do it better than IBM.

Happy Holidays!

December 22, 2015

Healing Back Pain

I've put off writing this post for many years because I know it will be controversial.  But we're a few days from Christmas, and I also know this post will be a wonderful gift for some people.

Chronic or intermittent pain, often located in the back, neck, and/or buttocks, is a major driver of personal suffering and reduced productivity in the US and other affluent nations.  While pain can obviously have a variety of structural causes, such as sprained ankles or bruising, garden-variety back pain usually doesn't.  I've come to believe that such pain is usually psychosomatic in nature-- in other words, caused by the brain but resulting in physical signs and symptoms in the body.  It's widely accepted that a person's mental state can affect pain perception, but this idea goes further.  Pain isn't just exacerbated by a person's mental state; it's often entirely caused by it.

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December 17, 2015

Unity Farm Journal - Third Week of December 2015

December continues to be unseasonably warm.   The bees are very confused - breaking cluster and leaving their hives in search of nectar which is not available this time of year.   We’ve created feeding boards for each hive, covering a hardware cloth screen with a patty of sugar.     The bees will recover, but we’re worried about the fruit trees and bulbs, which seem to think it is Spring.   If full budding occurs now, the buds will die in January when the cold and snow return.

I just finished the Fall semester of my Umass Stockbridge Farming program, Organic Vegetable Production.   For my final paper, I created an organic treatment plan for Unity Farm in the framework of a local pest and disease primer for Sherborn, Massachusetts.  Here’s the full text of the paper 

The work on the mushroom area I described last week is now complete.   We have a comprehensive mushroom management plan, infrastructure, and processes.    Kathy and I have about 150 new logs to inoculate and the racks are ready to store them.


Last weekend we completed the last barn cleaning before winter, using our large shop vac and industrial strength Stihl Magnum blower to remove all the hay, dirt and dust that had accumulated over the year.   In theory, the animals will be spending time in the barn soon, when the first snows of winter fall.    The barn is so clean and orderly that a visitor suggested we be nominated for “Farm Beautiful” magazine (which does not exist).



The ground is still thawed and we finished all our 2015 planting - 10 new beds of American ginseng as well as 6 new Korean Bee Bee trees , a late summer bloomer to extend the nectar sources for the hives into the Fall.


As the end of the year approaches, I’m very happy with everything we’ve accomplished at Unity Farm this year.   There are a few small items we’ll need to improve our workflow.  It’s time to prepare the Christmas list, which I’ll share next week.

December 16, 2015

The December 2015 HIT Standards Committee Meeting

The December 2015 HIT Standards Committee focused on 3 key projects as we wrapped up our work for the year.

Cris Ross presented the work of the  Certified Technology Comparison Task Force .  The idea behind this work is simple.   Although certified technology includes a number of specific functions outlined in various regulations, it may or may not be fit for purpose by a given specialist or in a given clinical environment.  The group seeks to Identify the different health IT needs for providers across the adoption and implementation spectrum, with particular focus on providers with limited resources and/or lower adoption rates and publish tools to enable comparison of different applications.    Hearings from many stakeholder groups are planned.

Chris Chute and Floyd Eisenberg presented the recommendations of the Transitional Vocabulary Task Force.     Over the years, the HIT Standards Committee has learned that optionality is barrier to interoperability.   Offering a choice of different standards - an “or” - becomes an “and” for developers as well as creates data heterogeneity among clinicians using different vocabularies.     The task force recommends eliminating different vocabulary choices over time and implementing a single vocabulary per domain i.e. SNOMED-CT for all problems/diagnosis and LOINC for diagnostic study names.

Finally, Jon White presented an update on the Precision Medicine Task Force, identifying enabling standards.

Our next meeting on January 20 , 2016 will include all the members of the Policy Committee and Standards Committee.   It will be my last meeting and I will pass the baton to my successors Arien Malec and Lisa Gallagher.   I know the  HIT Standards Committee will be in good hands!

December 10, 2015

New Evidence Strengthens the Link Between Hypothalamic Injury, Obesity, and Insulin Resistance

Obesity involves changes in the function of brain regions that regulate body fatness and blood glucose, particularly a region called the hypothalamus.  My colleagues and I previously showed that obesity is associated with inflammation and injury of the hypothalamus in rodent models, and we also presented preliminary evidence that the same might be true in humans.  In our latest paper, we confirm this association, and show that hypothalamic injury is also associated with a marker of insulin resistance, independently of BMI.

Introduction

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Unity Farm Journal - Second Week of December 2015

We’ve had a very warm December that has enabled us to do much more outdoor work than usual.    The effort of the past weekend  focused on refining our mushroom areas and permaculture plantings.  

Our end goal is 500 logs in production as follows

360 Shitake logs (4-8”) on 30 a-frames (pictured below)
 36 Shiitake logs (8-12”) on 12 4x4 bases
 24 Ganoderma Lucidum (Reishi) on the ground
 24 Nameko (Japanese mushroom) on the ground
 56 Oyster totems

We’ve decided to discontinue Lion’s Mane (poor yield) and retire those oyster logs that are no longer fruiting.    Last weekend we used the Terex front loader, forks, and our manure hauling trailer to move all the old logs into an a large pile adjacency to the orchard road where a commercial grinder can reduce them to wood chips for our trails.

Going forward we’ll focus on Shitake for 3 reasons
1.  Price point is nearly double of other types of mushrooms
2.  Shelf life is weeks, not days
3.  Fewer insect pests attack Shitake

Next weekend I'll be wrapping up my latest University of Massachusetts course, Organic Vegetable Production.   My final paper “Organic Pest and Disease Control in Sherborn, MA” covers all my experiences raising vegetables at Unity Farm, as well as the experience at surrounding farms - Sunshine, Sweet Meadow, and Dowse.    It will serve as a primer for agricultural practices at Unity for years to come.

As the holiday season approaches, we’re getting ready for the visit of family and friends.   As farmers, we’re very tolerant of our close partnership with the land and the animals we support.  We do not impose our lifestyle on any visitor.   If you want to shovel manure, you can, but there is no expectation that any visitor will follow our daily routines.   Tree house climbing, zip lining, hay hauling, forestry management and tractor driving are only for the willing!

It’s deer hunting season in Massachusetts (shotgun Nov. 30 – Dec. 12 and Primitive Firearms Dec. 14 – Dec. 31).   Local deer seem to know that Unity Farm is a vegan/vegetarian priority, so we have a deer freeway around our barnyard.   The alpaca/llama do not like deer (not clear why) and tend to trumpet in alarm when deer graze around our paddocks.    The Great Pyrenees always react to alpaca alarms with their own barking,  all night long.     You may have seen memes of the World’s Most Interesting Man - “I don’t always….”   Here’s our version:


We've posted no hunting signs every 50 feet around the perimeter of our 15 acres.   Given that rifle bullets can travel miles (assuming they miss their target and trees), we need to ensure our 150 animals are not harmed in any way during hunting season, so we have created a buffer zone using our property and surrounding properties.   We are careful to wear bright colors and avoid runs through the forest at dawn and dusk during hunting season.   I look forward to less 3am barking when the deer return to their usual range after hunting season!

December 09, 2015

The State of Information Security 2015

When I wrote about the most important healthcare IT stories of 2015 (such as ICD-10 and Meaningful Use), I did not include a discussion of Information Security.   That’s because security deserves its own post. Increasingly complex threats and an array of new security technology, policy, and education projects consumed us all in 2015.

Last week, I met with the Department of Justice Attorney General for National Security.  His message was clear.  With state-sponsored cyberterrorism and organized cybercrime on the rise, every internet connected device will eventually be compromised.  The only question is when.  By the way,  he works in a safe room without an internet connection.

2015 has been filled with denial of service attacks, hard to detect malware, and a skyrocketing number of personal internet connected devices at the same time that HIPAA enforcement has expanded.   The traffic on my guest networks from visitors using mobile devices has exceeded the traffic on the business network.   Meaningful Use requires us to share more information with more people for more purposes, but the HIPAA Omnibus Rule requires us not to lose a byte.

How did we survive the security challenges of 2015?

First, it is important to understand the threats and mitigate those vulnerabilities with the highest likelihood of being exploited and doing the most damage.    What is the #1 risk?

People.

The cartoon below illustrates the problem.


We spend millions on new technology, countless hours on policy writing, and engage all stakeholders to enhance their awareness.    Yet, we’re as vulnerable as our most gullible employee.

The scenarios I’ve seen in 2015 include:

*a clinician downloads an infected copy of Angry Birds to an android phone then logs into email.   The username and password is captured by a keystroke logger embedded in the running game software.   Massive spam is sent and the email domain is blocked by commercial internet providers

*A carefully crafted email encourages clinicians to login to Oracle financials to claim their yearly bonus.  A hospital’s Oracle Financials site is mimicked at a reasonable sounding URL.     Usernames and passwords are stolen and are used to change direct deposit information in the real Oracle Financials application.

*Social networks are used to infiltrate home computers and steal credentials.

Not only have we significantly increased our education efforts, but we’ve also put various filters on incoming email to scan every embedded URL and every attachment before delivering messages.   We’ve implemented various filters to prevent outgoing mail and internet traffic from exfiltrating sensitive data.  We require attestation that every device used by every person is encrypted and physically secured.

Our tools and dashboards identify variance in device, software, and people behavior.

Our security staff has been significantly increased.

Boards and senior executives are very sensitive to the reputational risks around security.   Security is supported by committees that include working groups, senior management compliance groups, and Board groups.

I’ve signed several vendor contracts in 2015 that include new liability and indemnification language protecting BIDMC against third party claims around breach issues.

The bottomline for 2015 - the threats increased and the technology, policy, and education efforts were redoubled.    Although ICD10 and Meaningful Use work may be diminished in 2016, security work is likely to increase.   As I’ve told the Board, security is a process, not a project.   You’ll get better and better but will never be done.

December 07, 2015

Bingo Medicine

It was a dark and stormy night. My computer didn’t catch fire while typing the previous sentence. No alarms were triggered warning me about the quality of such opening. I wasn’t prompted to select subjects and predicates from dropdown lists. I typed the entire sentence, letter by letter, not at all dissimilar to its first rendering back in 1830. Computer software in general, and Microsoft Word in particular, magically removed the hassles of quills, ink, paper, blotters, sharpeners, ribbons, whiteout, carbon paper, dictionaries, and all the cumbersome ancillary paraphernalia needed to support authoring, but made no attempt to minimize the cognitive effort associated with writing well.  Authoring great literature today requires as much talent and mastery as it did in the days of Edward Bulwer-Lytton.
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For several decades, software builders have tried to help doctors practice medicine more efficiently and more effectively. As is often the case with good intentions, the results turned out to be a mixed bag of goods, with paternalistic overtones from the helpers and mostly resentment and frustration from those supposedly being helped. Whether we want to admit it or not, the facts of the matter are that health IT and EHRs in particular have turned from humble tools of the trade to oppressive straightjackets for the practice of medicine. Somewhere along the way, the roles were reversed, and clinicians of all stripes are increasingly becoming the tools used by technology to practice medicine.

A common misconception is that EHR designers produce lousy software because they don’t understand how medicine is practiced. The real problem is that many actually do, and the practice of medicine is precisely what they aim to change. These high clerics of disruptive innovation would have you believe that “resistance to change” is equivalent to the resurrection of paper charts, thick ledgers, and medical information coded in secretive hieroglyphs. The truth is that physicians want to use modern computers, but they resent being used by computers. And the truth is that if we shed the orthodoxy imposed on us by self-serving “stakeholders”, computer software can indeed help address various problems in health care, some in the here and now, most in a distant future.

One thousand and one elements

This may sound strange to some, but the first step towards putting EHRs back on the right track should be to stop trying to help physicians practice medicine. Clinical decision “support” in the form of alerts, disease specific templates, mandatory checklists, required fields and rigid workflows are some of the things that must be removed from EHRs for two reasons. First, most of these “features” don’t work very well anyway. Second, more often than not, the real purpose of said support is not clinical in nature. For example, alerts about generic substitutes for brand name medications, data fields that must be filled and checkboxes that must be clicked to satisfy billing codes, PQRS or Meaningful Use, and the wealth of screens to be traversed before an order can be placed, have no clinical value.  And in most cases the opposite is true.

Some experts argue that EHRs are failing because they are nothing more than an old paper chart rendered on a computer screen. Many others are outraged by the fabled lack of interoperability (dissemination of information) or the lack of EHR usability, i.e. number of clicks, visual appeal, color schemes and ease of information retrieval. I would suggest that these dilemmas are peripheral to the one foundational problem plaguing current EHR designs – the draconian enforcement of structured data elements as means of human endeavor.

When Google mapped the Earth, it did not begin by mandating how to build and name roads and buildings. When we indexed and digitized books and articles, we did not require that authors change the way they write prose or poetry. When we digitized music, we did not require composers and performers to produce binary numbers at equidistant time intervals, and we did not make changes to musical instruments to allow for better sampling.  We built our computerized tools to ingest, digest, slice, dice and regurgitate whatever humanity threw at us, without inconveniencing anybody. This is why good technology seems magical.

EHRs on the other hand, are obnoxiously demanding that people change how they think, how they work, and how they document their thoughts and actions, just so that the rudimentary software prematurely thrust upon them can function at some minimal level of proficiency.  People don’t think in codified vocabularies. We don’t express ourselves in structured data fields. Instead of building computers that elegantly adapt to the human modus operandi, EHRs, unlike all other software tools before them, demand that humanity adjust itself to the way primitive computers work. The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.

All the pretty horses

What is the purpose of EHR documentation templates? There is practically no EHR in use today that does not include visit templates. Visit templates are a list of checkboxes, some with multiple nested levels, which allow documentation by clicks instead of by typing, writing, drawing or dictation. Visit templates are created for each disease and contain canned text for findings judged pertinent to that condition by template creators. In all fairness, many physicians like documentation templates because with just a few clicks you are able to generate all the documentation required nowadays to get paid for your work, pages and pages of histories, review of systems, physical examination, assessments and plans of care. Do doctors like templates because they believe this extensive documentation is necessary, or do they like templates because the checkboxes alleviate the pain of typing thousands of meaningless regulatory words? I suspect the latter.

Clinical templates, along with the automated clinical decision support they enable, are advertised as time savers for physicians. The time saved is the time previously spent with patients, and most importantly the time spent thinking, analyzing, and formulating solutions. For most, it’s also the time spent rendering thoughts in a manner that can be understood by another person. Furthermore, when your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say. Even in “efficient” practices where staff does the clicking and physicians have the luxury of asking “open ended” questions, the patient story, the quirky details that are irrelevant to the template, are not documented (highlighted, circled, noted on the margins, etc.) anymore. Is this a good thing?

If we proceed on the assumption that IBM Watson and the likes are eventually going to be artificially intelligent enough, and big data are eventually going to be big enough, to respectively analyze and represent a complete human being, then yes, we can safely dispense with old fashioned human expertise. However, we are most certainly not there yet, and regardless of industry rhetoric, we are not certain that we will ever be there, and we are not even sure that we want to ever be there. While this utopia (or dystopia) is portrayed by interested parties as “inevitable”, chances are that for at least several generations we will be forced to contend with imperfect digital renditions of medicine, instead of allowing EHRs to follow the growth of underlying technologies. This is akin to summarily confiscating and shooting all the horses, on the day Henry Ford rolled the first Model T off his assembly line. Where would America be today, if we did that on October 1, 1908?

Furthermore, what type of doctors are we producing when we teach medicine by template, supported by clinical decision aids based on the same template, and assessed by quality measures calculated from template data? Medicine does not become precise just because we choose to discard all imprecise factors that we are not capable of fitting into a template. Standardization of processes and quality does not occur just because we choose to avert our eyes from the thick edges were mayhem is the norm. Dumbing physicians down is not the optimal strategy for bringing computer intelligence closer to human capabilities. EHRs should not be allowed to become the means to stifling growth of human expertise, the barriers to natural interactions between people, or the levers pushed and pulled at will by greed and corruption.

Bildungsroman style

Instead, EHRs could be the scaffolding for IMB Watson and other emerging contraptions to grow and become truly useful tools for both doctors and patients, and yes, also for legitimate and beneficiary secondary uses of clinical information. Instead of mandating that doctors think and work in ways that serve Watson’s budding abilities, we should require that Watson learns how to use the normal work products of humans. Instead of enforcing templated thought and workflows, whether through direct penalties for doctors or indirect certification requirements for software, we should work on teaching Watson how to parse and use human languages in all their complexity. Watson should grow up to be the multi-media scribe behind the computer screen, the means by which the analog music composed by physician-patient interactions is digitized into zeros and ones without loss of fidelity and without interference with actual performance.

Billions of years of evolution endowed the lowliest human specimen with cognitive abilities that machines will most likely never attain. The glory is in the journey though. We need to accept delayed gratification, and we need to accept that the challenge will span centuries, not just one boom-bust cycle of a fleeting global economy. We need to accept the fact that we will all die long before the ultimate goals are achieved, instead of declaring victory whenever each negligible incremental step is taken. If we are going to create a new form of intelligent life on earth, we need to assume the same humility Nature, or God, has been exercising since the dawn of time and counting. Otherwise, we are all just a bunch of hacks looking to make a quick buck on the backs of our fellow men and women.

December 06, 2015

2015 Vegan Gift Guide

Things have been silent around here for a while (same old, same old) and although I don't plan on updating much more in the future, I thought it would be nice to do a little vegan gift guide now that it's the holiday season. You see I have been struggling quite a lot trying to fully transition to a vegan lifestyle. Don't get me wrong, I've completely sworn off meat, dairy, eggs, honey and whatnot but I'm still surprised to find out how many different things in our everyday life contain animal products. That is why I've compiled this miniature guide to help you find your loved ones 100% cruelty free but nonetheless awesome Christmas presents.


Hopefully you'll find this guide helpful and perhaps even get some ideas for your own wish list. If you'd like to leave your own recommendations below, I would be more than happy to read them! So let's get to it!




I. Love. These. Watches. Classy, timeless and gorgeous timepieces that will make the perfect gift for anyone in your family! Literally everyone, as they have both small ones and big ones, ladies' and men's, classic styles and bolder colours. They also offer free shipping worldwide and my very own promo code "TILDASDW" will get you 15% off until January 15th! Yay! (Also, go for the Nato Wristbands to stay vegan!)


2. CLEAN Perfumes

Let's be honest, we can't always be bothered trying to find specialty vegan store and brands to buy all our stuff. As much as I love visiting these shops, it can really be a pain in the ass to have to go halfway across Stockholm just to find a vegan perfume. Enter CLEAN perfumes,  100% cruelty free, mainstream and absolutely wonderful! My favourite is the White Woods pictured above but all of their scents are beautifully fresh and well, clean. A vegan must-have.


3. Handmade Heroes Beauty and Skin Care

I was lucky enough to receive an adorable little care package from Handmade Heroes a while ago, filled with some of their vegan beauty products. Pictured above are their green clay face mask, coconut lip scrub and two different lip tints. The gorgeous packaging aside, I've genuinely enjoyed using these products and the lip scrub is so natural that you can eat it. It actually tastes really nice hehe. Though I would suggest you don't have it all for an afternoon snack. That would be a total waste of lip scrub.


4. Vegan Chocolate

Nowadays there are numerous vegan chocolate brands to choose from and getting your loved ones their chocolate fix doesn't have to involve any cow's milk whatsoever. I have included a few of my favourite kinds above, namely Pana Chocolate, The Raw Chocolate Company, Lovechock and Squarebar.  The Pana Chocolate is amazingly silky and has a softer texture than the other tree while The Raw Chocolate Company and Lovechock are both more like traditional dark chocolate but -obviously- better. My absolute favourite would have to be Lovechock's Mulberry Vanilla. Lastly we have the Squarers which are actually more of a chocolate coated vegan protein bar but I had to include them on this list as well as they're just so darn delicious. One of the best,most indulgent vegan protein bars out there!

Hope you've enjoyed reading this post and that you'll all have the best holiday season surrounded by family and friends! Much love to you all!

December 03, 2015

Unity Farm Journal - First Week of December 2015

Thanksgiving was a busy time at Unity Farm, turning our harvest into dinner for the family, “in-laws to be”, and all the animals.  

Life on the farm is one of constant learning - every day is filled with new experiences and challenges.  We somehow muddle our way through.

On Thanksgiving, one of our Americauna chickens, Amelia, was scared by a fox and hid under the shed in our pasture.   At times,  various creatures hide under the shed, but they always come out.   Two days later she was still under the shed and we had to take action.   The usual techniques - bamboo poles, a Stihl blower and 2x4s did not work.  We had no idea what to do, so we improvised.   We waited until after dark and when she was asleep we dug a trench under the shed and I delicately grasped her legs, protected her wings, and brought her back to the coop.   She ate and drank heartily.   At this point, she probably thinks the shed incident was just a dream.

We are a commercial kitchen and thus every year we have to sterilize our well to ensure good hygiene - no soil coliforms.    Our well is 300 feet deep and 6 inches in diameter.  Think of it as a 450 gallon column of water.     We add half a gallon of  8% sodium hypochlorite solution (germicidal bleach), then flush the resulting solution through all the pipes in the property.    This year, we did our sterilizing a week before our Thanksgiving guests arrived and all went well.   With all the guests in the house, water usage peaked and they drew down on the column of water much faster than Kathy and I would.    The end result was that more bleach passed faster  through the pipes than usual and the iron in the water precipitated turning our water orange/red.   We had no idea what to do so we improvised.   We connected a hose from the house to the well and ran it for 4 hours, passing it through a course filter along the way.      The end result was clear water with minimal chlorine smell.

The tractor parts we ordered for winter arrived this week - a pair of forklift forks and a 52” snowblower attachment for the Terex.   I’m very excited about sitting in the Telex, listening to 1970’s tunes, staying warm/dry, and moving 10 tons of snow per hour.

Last Fall we planted Ginseng - 5000 seeds and 500 roots on an east facing slope.   The deer ate many of our seedlings and it was not clear how many sprouted.  This year, we’re taking a more scientific approach.   Last weekend I built 10 raised beds laid out in a grid around the property - in shade, partial shade and partial sun.   In wet soil and moist soil.   In oak woodland and maple woodland.    I fenced each area using 5 foot welded wire fence on 6 foot T-posts.  By next May we’ll be able to count successful seedlings and determine what environment is best.

Now that every night is dipping below freezing, I covered every raised bed in the hoop house with row covers to enable growth even in the low 20’s.    At this point, our spinach, chard, lettuce, turnips and carrots are still doing well under row covers despite freezing nights.

Next weekend I will begin refining our Mushroom log collection based on what fruited this Fall and what did not.  I’ll retire some logs and layout new areas for freshly inoculated logs.   Our plan is to keep a steady state of 500 Shiitake logs, 24 Reishi mushroom logs, 24 Nameko mushroom logs, and 50 Oyster logs.    As a farm, we need consistent production that matches supply and demand.   After this weekend, our mushroom areas will be optimal.

December 02, 2015

2015 In Review

It’s now December and as each year ends, I always look back on the challenges and achievements of the past 12 months.    Here’s my sense of 2015.

ICD10 - billions were spent, countless other projects were delayed, and the transition occurred on October 1 without a major incident.   We’re monitoring daily cash at all our hospitals and there has not been significant impact on denials, payments, or discharged but not final billed accounts.    Did we get our money’s worth?    I have argued and will continue to assert that ICD-10 benefited no one.  The diagnoses used are more variable so there is less precision in their use.  Clinical documentation (in general in the industry) does not have the specificity needed to justify the more granular ICD-10 codes.    The notion that quality measures can now be computed more accurately from ICD-10 coded administrative data is just not true.     The right path is to plan for a future in which fee for service is replaced by bundled payments so that ICD vocabularies do not need to be used at all for billing.    Natural language processing  will be able to turn unstructured text into SNOMED-CT coded observations to support analytics.    I know that ICD-9 is obsolete and did not include many modern concepts.   However, we should have saved our billions and waited until natural language processing and SNOMED-CT was ready (or a convergence of SNOMED-CT and ICD ideas such as will be implemented in ICD-11)  http://www.icd10monitor.com/enews/item/1399-icd-11-a-code-set-for-the-future.   The end result of years of work 2012-2015 is that many IT stakeholders think IT was distracted by projects that added little value.  The good news is that now that ICD-10 has passed, we can return control of IT priority setting to customers.

Meaningful Use - Stage 2 was revised and Stage 3 was finalized with a comment period.    We can only hope that the comment period convinces CMS and Congress to shift the Meaningful Use program into a merit-based payment incentive program, acknowledging the Meaningful Use has achieved its goals.   Just as with ICD10, we need to turn the IT agenda back to customers - patients and providers - who want improved quality, safety and efficiency.   As we’ve seen with Stage 2, it is too early to propose a Stage 3, because we do not really know what has worked in Stage 2.   I have advocated for moving to an outcomes approach.    If you want to give Apple Watches to all your 80 year olds to monitor their exercise patterns and support a patient-based medication administration application on the watch, go for it.   If you want to hire high school students with clip boards to visit elderly patients and do home checks, go for it.   The outcome might be better health and fewer hospitalizations.   The tactics should be up to patient centered medical homes and ACOs, not regulation writers.     My secret hope is that CMS decides to remove the penalty phase of Meaningful Use, enabling every EHR vendor to ask their customers - should we spend the next 3 years implementing the Certification rule (which is voluntary) or just ignore the entire Meaningful Use program and innovate to accommodate the needs of alternative payment models?  My guess is that the majority of hospitals and professionals would tell vendors to abandon the certification effort and focus on value added enhancements.   At that point, the Meaningful Use program could be considered a success and be moved into a historical status - still on the books, but not pursued by most.

HIPAA Omnibus Rule - In 2015 we were told to share more data with more people for more purposes, but to never allow a single byte to go astray - an impossible task.    OCR stepped up HIPAA Audits and enforcement at a time when threats from cyberterrorists, organized crime, and hackivists peaked.    Rather than focus on all the vulnerabilities and the mistakes made as documented on the wall of shame, I’m hoping that as a country we can focus on the positive - working together as a society to identify the real threats and collectively take action to mitigate risk through policy, education and technology.    We need to stop creating a climate of adversity among regulators, providers and IT departments.    Later this week, I’m meeting with National Security leaders from  the Department of Justice.   I can only hope they will propose a collaborative, positive approach.

Affordable Care Act - 2015 was a year for big data analytics.   BIDMC’s ACO was the #1 ACO in New England and #3 nationally, in part because of our ability to aggregate a common data set of clinical and financial data from 26 EHRs (all our loosely affiliated clinicians).   We used this data for care management, quality analytics, and benchmarking.   We saved Medicare $50 million in 2015 alone.    It’s clear that turning data into wisdom through the use of novel visualizations, alerts and reminders works.    Meaningful Use did not tell us to do this.   The Affordable Care Act told us to achieve an outcome and innovation happened because incentives were aligned to motivate us.

Cloud  -  2015 was the year in which the cloud became a viable option for just about every application in healthcare.   Amazon and Google both agreed to sign business associate agreements.    Many companies offering cloud-hosted services agreed to indemnification clauses for privacy breach.   At this point, the cloud can be more reliable, more secure, and more agile than local hosting.    Pilots for BIDMC include moving our development/test environments and disaster recovery to Amazon.    Production systems are likely to follow.

There you have it - 2015 has come and gone with major federal programs winding down and control being returned to the private sector.   I’m incredibly optimistic about 2016.   As I’ll write about soon, our agenda is filled with new ideas and it feels as if the weights around our ankles (ICD10, MU) are finally coming off.