Building Unity Farm - Preserving the Harvest

As Fall approaches in New England we're picking apples/fermenting cider, extracting honey, canning jams, preserving vegetables, and finishing our Fall mushroom inoculation.

Here are a few scenes of the harvest - a very busy time of year.

The Unity Farm orchard contains 36 trees - Apples, Cherries, Peaches, Pears, and Plums.   We have 180 high bush blueberry bushes and 150 low bush blueberry bushes.    We have elderberry, raspberry, and pecans.    Here's an overview of the layout.

Last weekend we picked Honeycrisp, McIntosh, and Asian Pear.    We crushed the apples into cider and pasteurized it into quart containers.   Here's what the process looked like in the cider house.

In August we picked blueberries and created Unity Blue jam, a mixture of berries and other natural ingredients from the farm.    We've applied for a license to sell our farm products at farmers markets and other retail locations.   As soon as the license is granted we'll be able to sell Unity Blue - here's what the finished package looks like.

I'll write an entire post about the honey extraction process, which requires a bee suit, a smoker, a hive tool to gently remove the frames containing combs of honey, a tool to uncap the combs, and an extractor to remove the honey from the wax.    We gathered 240 ounces of honey from our 8 hives and we will leave all remaining honey for the bees to use over winter.   Below is the alternative u-pick method, that we've chosen not to use!

Finally, we've prepared 220 shitake, 72 oyster, and 6 lion's mane logs so they are ready to fruit with mushrooms in the Spring.   Here's a view of our laying yard where oyster mushrooms are growing on poplar.   Our shitake and lion's mane logs are kept in the shade house.

We're on the cusp of selling the products of Unity Farm.   By next year, we should have commercial quantities of fruit, vegetables, mushrooms, honey, and fermented cider.   The great thing about life in New England is that each season brings a new adventure and as we finish our harvest, we can dream about the new farm possibilities we'll have in the Spring.

EMAR Go live

On September 4, BIDMC went live with its innovative web-based, mobile, "Amazon.com shopping cart" inspired electronic medication administration record.

Using a combination of iPads, iPhones, bar code readers, and thin client (HTML, Javascript) cloud hosted software, we have eliminated paper-based medication records on a major medical floor.   As is typical with our user centered design methodology, we'll incorporate improvements as we incrementally implement the software across the enterprise.

Our standard user centered design process includes:
  *Clinicians define requirements in our governance committees
  *Clinicians and developers create products
  *Limited pilots are conducted and feedback gathered.
  *Revisions are made and re-piloted
  *When clinicians judge the product to be mature, pilots are expanded and phased rollout is done.
  *Governance committees meet monthly to review functionality and prioritize enhancements.

The entire process is agile, clinician focused, and continuous

Although BIDMC builds and buys software based on requirements and product maturity, EMAR is a perfect example of when clinicians writing software for clinicians makes great sense.

Nurses created the user interface following of the motif of the Amazon.com shopping cart - you "buy" medications with one click when giving them to a patient, then "check out" to record your "purchases" in the permanent medical record.    All of this happens in real time as bar codes are scanned.   iPhones show each nurse what has been ordered and what has been administered.  iPads at each Omnicell medication cabinet show nurses what work needs to be done.

Here are a few screen shots

Comments from nursing thus far have included "this saves me so much time", "an incredible enhancement", "a major safety gain".   Rarely have I attended a go live debrief in which all the stakeholders expressed such joy and satisfaction.

Clinicians designing software for clinicians, using mobile and thin client cloud hosted approaches, with continuous improvements during enterprise rollouts.   It's a formula that works for our culture.

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.