Connecting the Meditech Hospitals in Massachusetts

Yesterday I joined several Massachusetts CIOs at a Meditech healthcare information exchange kickoff meeting.  

Here are the slides we used.

Meditech has chosen to do the right thing - support the Direct protocol without requiring a vendor specific HISP, an interoperability "subscription" or transaction fees.    Nationwide, any of Meditech's Meaningful Use Stage 2 certified platforms - Magic 5.66, Client/Server 5.66, or  6.07  can support the Direct implementation guide (SMTP/SMIME) and the SOAP/XDR addendum.

The Massachusetts HIE, the Mass HIWay, has been live since October 2012 and now transports thousands of transactions per day among providers, payers, patients, and government.  Our goal in 2013 is to add more organizations and more use cases.    Meditech provides about 70% of the hospital information systems in the Commonwealth, so it is critically important that Meditech integrates well into the state's cloud-based HISP.

Over the next few months, a diverse array of hospitals will work closely with Meditech and state government to implement production HIE transactions.

Earlier adopters will include Jordan Hospital, Holyoke Hospital, Winchester Hospital, Berkshire Health Systems, Harrington Hospital, and Exeter Health (New Hampshire)

Use cases include transition of care summary exchange, public health reporting. lab results reporting, admission notification, and ED arrival notification.

Once these pilots are complete, we'll spread Meditech connectivity through the Commonwealth.

With other EHR vendors, which are requiring vendor specific HISPs, we're still working through the trust issues (authentication is easy, authorization is harder) that enable HISP to HISP communications among those clinicians who have agreed to all our privacy policies.    Once this work is done the number of clinicians with HIE connectivity will accelerate as network effects incentivize data exchange for care coordination, care management, and population health.

Building Unity Farm - Emergency Preparedness

In the month of June, we've had 10 inches of rain at Unity Farm (to view our weather station data click here).

Although our paddocks, pastures, and trails are normally dry, we've accumulated water in ways that impacts our ability to care for the animals.  The picture above shows one of our paddocks after a deluge of rain.   A manure pile that is under water is a bad thing.

What did we do?   I purchased a 1/2 horsepower submersible sump pump  and attached 1 1/4 inch sump pump hose to maximize outgoing water flow - a garden hose would have been too limiting.     Sump pump hose is sold in 25 foot segments because sump pumps are designed to go from basements to outdoors over a short distance.   In our case, we needed to pump 40,000 gallons of water into  a dense forest that would easily absorb the flow and return it to our water table.   I used 1 1/4 barbed couplings and hose clamps to link together 150 feet of sump pump hose.  

I built a cage of 23 gauge hardware cloth and submerged the pump inside the cage to ensure floating debris did not clog the pump.

The end result was a water flow of about 4000 gallons an hour from paddock to forest.   After 12 hours of pumping, the paddock was transformed from a lake to puddle.  

After mastering this technique, we're now ready for any flood related emergency.

Too much water is one challenge, but what about too little?   We have a well that consistently produces 8 gallons per minute of clear, chemically perfect water.  However, the well depends upon electricity.    If we lose power due to a storm, we have 50 gallons stored in the basement which will serve the needs of the household.   But, what about the animals?

To ensure we can keep all the animals of Unity Farm hydrated, warm, and safe, the farm has a 20 kilowatt generator and four propane tanks.   The entire barn, heating system, food storage, water supply, and internet connection can run off grid for a few weeks.   The pump system I described above is powered from the chicken coop, which is also backed up by the generator.

Last year, we replaced all the well equipment which had reached end of life.   In addition to water flows to the barns and paddocks, we do have drip irrigation keeping all our fruit trees and produce plantings moist.    Just as we're ready for floods, we're also ready for droughts.

Finally, we have a fully stocked root cellar with about a year of food kept at 60 degrees, so if there is a very significant man-made or natural disaster, we should be self sufficient.

Every day at Unity Farm is a learning experience.  Thus far, our emergencies have been few, but we're prepared for whatever may come.

The June HIT Standards Committee

The June HIT Standards Committee focused on novel transport standards for patient mediated exchange, an overview of patient/family engagement tools, updates on formulary downloads, use cases for image sharing, and lab ordering standards.

Dixie Baker and David McCallie presented the NWHIN Power Team review of the emerging transport standards for consumer exchanges that I believe will accelerate all types of interoperability in the next few years - the HL7 Fast Healthcare Interoperability Resources (FHIR, pronounced "Fire") initiative , the RESTful Health Exchange (RHEx) Project and the Blue Button Plus (BB+) Initiative.   It's clear to me that the combination of REST for transport, OpenID/OAuth2 for authentication/authorization, and FHIR for content will be a winner as we scale interoperability to the national level.

Next, Leslie Kelly Hall presented the efforts of the Consumer Technology Workgroup to prioritize patient and family engagement standards including structured data capture from forms/questionnaires and care plans.

Jamie Ferguson, with John Klimek from NCPDP, presented the preliminary recommendations of the Clinical Operations Workgroup for adoption of formulary standards.    We also discussed use cases for image exchange (provider to patient, provider to provider, provider to care team) and endorsed the S&I framework efforts on lab ordering standards.

Finally, Doug Fridsma and Set Pazinski provided an ONC update.

A very good meeting with exciting new standards evolving to support Meaningful Use Stage 3 and beyond

Making a Difference

Although I usually reserve Thursday for personal blogs, Father's Day was a time for reflection that enabled me to put aside the endless emails, operational tribulations, and budget season stresses to think about what really matters.

In my 51 years, 2013 marked the first time I've had no father with me on Father's Day.  For the first time, I've taken on the mantle of "alpha" father for the family.

I celebrated Father's day with my wife, daughter and her partner David, enjoying a Japanese lunch and helping them rewire the kitchen in their new apartment.   They rent one of 4 units in a 1910-era shingled house in Medford.   We braved the dungeon-like basement to find the old breaker box and located the power controls for the kitchen.    I taught them how a GFCI receptacle is wired, carefully isolating the Load and Line sides, the hot wire, the common wire, and the ground.    We then built new kitchen shelving for her pots and pans.    It was a perfect Father's Day, serving those around me and making my daughter's life easier.

I called my mother, as I have done every day since my father's death, to check on her progress.  She's gardening, taking daily walks, and keeping her brain busy with numerous cultural and social activities.

So, what part of this inspired me to think about what really matters?

Will my tombstone read

"He balanced his budget 20 years in a row"
"He addressed all regulatory requirements for over 2 decades"
"He completed all his annual operating plan goals and more"

Unlikely.

If in some small way, I empower my daughter to fledge from the nest, taking responsibility for running a household and finding her own way in the world, I will have created a legacy that could last for a century.

If in some small way, I enable my mother to maintain her wellness, learn new technologies, and experience a rich "act two" after my father's death, I will have made a real impact on her life.

Both are examples of making a difference.

As I look at my weekly calendar, about half my waking hours are spent on operations, a quarter on planning the future, and quarter in service to my family and community.

It's the last quarter, when I give my time, that has the greatest chance of impacting the long term future of those around me, accelerating the progress of the next generation, and catalyzing good outcomes in the world.

While balancing a budget is a must do, it's quickly forgotten.   You're only as good as your last budget cycle or your last successful project.

However, if your family, your colleagues, and your students feel inspired by something you've said, a situation you've created, or a barrier you've broken down, then you've created a memory that can last a lifetime.

So next time your equanimity is challenged by a person, situation, or event in your job, remember that such issues are transient.    Focus your emotional energy on that which really matters and you'll make a difference.   That's the pot of gold at the end of my rainbow (photo taken at Unity Farm a few hours ago)

Building Unity Farm - Little Glamour, Lots of Laundry

My wife and I owned and operated a small winery on the Marin/Sonoma border in Northern California when we were in our 20's - from 1986-1991.   When I told my colleagues at the time that I ran a winery, they commented on the romance, art, and elegant lifestyle it implied.   It was agriculture.  It was hot, sweaty, and dusty.   You could make a small fortune in the wine business - as long as you started with a large fortune.   I relished the experience, but it was not elegant.

In many ways, running a small farm is the same.   The notion of a hobby farm or gentleman's farm sounds so Thoreau.    In reality, it's a lot of laundry.

Every morning before leaving the farm at 6:45am for the commute to Boston, I feed the animals, fill their water buckets, and clean stalls.   I make sure that no predators visited overnight, that crops were watered by irrigation systems, and that compost is moist but not too moist.

The picture above illustrates what it's like to manage the manure of 50 animals - that's a 16x16x3 foot compost pile.

Farm work is extremely satisfying and is an essential part of maintaining my equanimity.  Shoveling manure, hauling hay, and splitting wood are very Zen.

The difference between farm life  and suburban residential life is the scale.

Have you ever mulched your garden?    The picture below is the mulch pile for the trails of Unity Farm.  I run the dogs on the trails every night and they enjoy climbing the wood chip pile before it becomes trail mulch.

Weekends are filled with joyful work - every moment from 6am to 6pm is constant movement.

By the end of the day, I'm covered with hay, dirt, manure, forest debris, and animal hair.

The clothing I wear on the farm is the same tough climbing gear from Arcteryx that I've worn for years as an alpinist.   Not only does it stand up to the rigors of farm work, it also lasts through the repeated washings (at least two per weekend) needed to return the fabric to its baseline state.

The scale of Unity Farm as described in our LLC filing and Chapter 61A application (agricultural status) is

"Unity Farm raises alpaca for fiber for production to spun yarns.
        This can include milling of blankets or other objects beyond yarn.
         Also possible is the sale of cria (baby alpaca), as a result of our breeding plan

Fruits, eggs, honey, and gourmet mushrooms are planned components of the farmstand.
          Possible addition of other seasonal crops from the hoophouse
          Local flowers possible
       
Considerations include pasturage, cropland, location of farmstand, and web sales. Ecotourism and Northeast Organic Farming Associaton certification are to be considered."

We're not an agribusiness, we're a local community resource.    We may be the size of a gentleman's farm  but we're not very gentlemanly.   Little glamour, lots of laundry.   If you want to try it yourself, here's some of the best advice I've ever found.