The August HIT Council Meeting
On Monday, the HIT Council met to review progress on health information exchange in Massachusetts. Here's the presentation we used.
You'll see that we've sent 1,349,083 transactions through the MassHIway.
Increasingly we're seeing subnetworks - aggregations of clinicians in regions of the state - joining the MassHIway to send transactions to other subnetworks. We've heard presentations from our colleagues in Holyoke and the Pioneer Valley, both of which have created exchanges specific to their clinical service areas. Our network of network vision is becoming a reality very quickly.
We're guided by a simple policy goal - to demonstrate measurable improvements in care quality, population health, and cost containment through use of health information technology
We're using grants to motivate stakeholders by:
-Encouraging vendor development of Direct-complaint interfaces, initiated within the workflow of their applications and that will enable use of the Mass HIway by Massachusetts’ providers
-Accelerate connections to the Mass HIway
-Grow transaction volume
Major vendors such as Meditech are in testing and major providers such as Partners and Childrens will go live soon.
BIDMC is sending thousands of transactions per day to registries, providers, payers, and public health. We're working with several grantees to expand the number and type of transactions including routing to patients/PHRs directly.
Our next major milestone is MassHIway Phase II which includes a master patient index and relationship locator service for "pulling" data with patient consent in an emergency.
So far, we're on time, on budget and making rapid progress with the MassHIWay. It's great to see sustainable HIE supported by the community and demanded as part of accountable care operations.
Thank You Farzad
This morning, National HIT Coordinator Farzad Mostashari resigned. His letter to ONC staff was profound. As I read it, I felt a lump in my throat. He will be missed.How much do I respect him? I have not worn a tie since Y2K, except for a bow tie last year in honor of Farzad.
I started working with Farzad when he served at the New York City Department of Health and Mental Hygiene as Assistant Commissioner for the Primary Care Information Project. I was an early champion of eClinicalWorks and Farzad unilaterally transformed that product from a good EHR to a population health tool.
As Deputy National Coordinator he brought operational rigor and a public health perspective to ONC.
As National Coordinator he brought energy, enthusiasm, and momentum to healthcare IT. He inspired, challenged, and influenced with informal authority, never a heavy hand. Hundreds of people volunteered to support his vision out of respect for his ideas and a sense that it was the right thing to do.
Some people seek fame and fortune. Some just want to make the world a better place. In all the years I've worked with Farzad, I've never sensed any self-interest. He has been mission driven.
Washington is a hard place to work. Some say that no one is your friend (except your dog). Hours are long, pay is poor, and travel is overwhelming. Burn out is hard to avoid when you've cleaned the Augean Stables and your only feedback is that you missed a spot.
Each of the national coordinators had a different style. David Brailer had the strong opinions that were necessary to establish a new federal office. Rob Kolodner led early technology efforts at time when the Bush administration offered limited funding for healthcare IT. David Blumenthal served as a noble statesman painting a vision for the HITECH program. Farzad was the implementer who turned the HITECH vision into policy outcomes by pure strength of will.
I believe Farzad will serve until the end of September. I'll do whatever I can to solidify the trajectory over the next two months so that the cadence of Farzad's strategic plan seamlessly transitions to the next national coordinator.
Building Unity Farm - Our Breeding Program
The small family farm is a physical and financial challenge. We're not quite ready to offer our products commercially but after our first year, we'veharvested 240 ounces of honey
inoculated 200 Oyster Mushroom logs
inoculated 200 Shitake Mushroom logs
planted 180 high bush blueberry bushes
planted 30 heirloom apple trees
sheared/gathered fiber from 12 llamas and alpacas
gathered over 1000 eggs from our 12 chickens
raised 12 guinea fowl
split 10 cords of wood
fenced 2 acres for produce and prepared land for 18 raised beds in a hoop house
By next Spring we'll have products ready for sale but if we add up the value of everything we sell it will be less than $25,000/year.
Breeding animals is one way a small family farm can improve its sustainability.
After carefully considering the pedigrees of our alpaca, we elected to breed Midas (our 4 year old gold colored male pictured above) with Ella (our 7 year old experienced mother) and Persia (our 4 year old maiden).
After reading several books about Alpaca breeding we decided that a July 2013 breeding leading to a June 2014 birth would align well with good birthing weather in New England. The gestation period of Alpacas and Llamas is 11 1/2 months and we really don't want labor to occur in the heat of August.
We moved Midas and Ella to our large pasture and left them alone for a few hours. Then, we returned them to their paddocks. The following day, we moved Midas and Persia to the pasture for a few hours.
We'll repeat the process this weekend. Alpacas ovulate on demand - they are always capable of becoming pregnant. We'll do a "spit test" for pregnancy in two weeks. How do we do that? After breeding, bring the pairs together. If the female spits, kicks, and generally rejects the male, she is pregnant. If she lies down and is ready to breed again, she is not pregnant.
Alpaca offspring are called crias and sell for $1500-$2500 on average.
We're also raising more Guinea Fowl this Summer. We've gathered 25 fertile eggs from nests left in the forest and placed them in our incubator. We keep the temperature at 99.5F and the humidity at 50%. We use an automatic egg turner to rotate the eggs every 6 hours. If we're successful, we'll have a new brood of guineas in 28 days and we'll raise them indoors for 12 weeks before moving them to the coop with the other adults.
Guineas are efficient tick and fly eaters, keeping our farm and yard free of biting and stinging insects. They also alarm (by squawking) whenever a predator or trespasser threatens. I would not recommend guineas for residential neighborhoods. Guinea fowl offspring are called keets and sell for $5 each.
2013 has been the year of raising and breeding animals. 2014 will be the year that our produce efforts first become commercial.
Just as with the wine business, I'm sure we can make a small fortune in family farming, as long as we start with a large fortune. More to come as I learn about the success of our breeding program and our overall economics.
Downtime in 2002 verses 2013
On November 13, 2002, the network core at Beth Israel Deaconess failed due to a complex series of events and the hospital lost access to all applications. Clinicians had no email, no lab results, no PACS images, and no order entry. All centrally stored files were unavailable. The revenue cycle could not flow. For 2 days, the hospital of 2002 became the hospital of 1972. Much has been written about this incident including a CIO Magazine article and a Harvard Business School case.
On July 25, 2013, a storage virtualization appliance at BIDMC failed in a manner which gave us Hobson's choice - do nothing and risk potential data loss; or intervene and create slowness/downtime. Since data loss was not an option, we chose slowness. Here's the email I sent to all staff on the morning of July 25.
2002 and 2013 were very different experiences. Here's a brief analysis:
1. Although 2002 was an enterprise downtime of all applications, there was an expectation and understanding that failure happens. The early 2000's were still early in the history of the web. There was no cloud, no app-enabled smartphones, and no universal adoption of social networking. Technology was not massively redundant. Planned downtime still occurred on nights and weekends.
In 2013, there is a sense that IT is like heat, power, and light - always there and assumed to be high performing. Any downtime is unacceptable as emphasized by the typical emails I received from clinicians:
"My patients are still coming on time and expect the high quality care they normally receive. They also want it in a timely manner. Telling them the computer system is down is not an acceptable answer to them. Having an electronic health care record is vital but when we as physicians rely on it and when it is not available, it leads to gaps in care."
"Any idea how long we will be down? I am at the point where I may cancel my office for the rest of the day as I cannot provide adequate care without access to electronic records."
In 2013, we've become dependent on technology and any downtime procedures seem insufficient.
2. The burden of regulation is much different in 2013. Meaningful Use, the Affordable Care Act, ICD10, the HIPAA Omnibus rule, and the Physician's Quality Reporting System did not exist in 2002. There is a sense now that clinicians cannot get through each day unless every tool and process, especially IT related, is working perfectly.
Add downtime/slowness and the camel's back is broken.
3. Society, in general, has more anxiety and less optimism. Competition for scarce resources translates into less flexibility, impatience, and lack of a long-term perspective.
4. The failure modes of technology in 2013 are more subtle and are harder to anticipate.
In 2002, networking was simple. Servers were physical. Storage was physical. Today, networks are multi-layered. Servers are virtual. Storage is virtual. More moving parts and more complexity lead to more capabilities but when failure occurs, it takes a multi-disciplinary team to diagnose and treat it.
5. Users are more savvy. Here's another email:
"Although I was profoundly impacted by today's events as a PCP trying to see 21 patients, I understand how difficult it is to balance all that goes into making a decision with a vendor on hardware/software maintenance. However, I was responsible for this for a large private group on very sophisticated IT, and I would urge you to consider doing future maintenance and upgrade projects starting on Friday nights, so as to have as little impact as possible on ambulatory patient care."
My experience with last week's event will shape the way I think about future communications for any IT related issues. Expectations are higher, tolerance is lower, and clinician stress is overwhelming. No data was lost, no patient harm occurred, and the entire event lasted a few hours, not a few days. However, it will take months of perfection to regain the trust of my stakeholders.
It's been 10 years since we had to use downtime procedures. We'll continue to reduce single points of failure and remove complexity, reducing the potential for downtime. As a clinician I know that reliability, security, and usability are critical. As a CIO I know how hard this is to deliver every day.
On July 25, 2013, a storage virtualization appliance at BIDMC failed in a manner which gave us Hobson's choice - do nothing and risk potential data loss; or intervene and create slowness/downtime. Since data loss was not an option, we chose slowness. Here's the email I sent to all staff on the morning of July 25.
"Last evening, the vendor of the storage components that support Home directories (H:) and Shared drives (S:) recommended that we run a re-indexing maintenance task in order avoid potential data corruption. They anticipated this task could be run in the middle of the night and would not impact our users. They were mistaken.
The indexing continues to run and must run to completion to protect H: and S: drive data. While it is running, access to H: and S: will be slow, but also selected clinical web applications such as Provider Order Entry, webOMR, Peri-operative Information System, and the ED Dashboard will be slow. Our engineers are monitoring the clinical web applications minute to minute and making adjustments to ensure they are as functional as possible. We are also investigating options to separate clinical web applications from the storage systems which are causing the slowness.
All available IS resources are focused on resolving this as soon as possible. We ask that all staff and clinical services affected by the interruption utilize downtime procedures until the issue is resolved. We apologize for the disruption this issue has caused to patients, providers, and staff."
1. Although 2002 was an enterprise downtime of all applications, there was an expectation and understanding that failure happens. The early 2000's were still early in the history of the web. There was no cloud, no app-enabled smartphones, and no universal adoption of social networking. Technology was not massively redundant. Planned downtime still occurred on nights and weekends.
In 2013, there is a sense that IT is like heat, power, and light - always there and assumed to be high performing. Any downtime is unacceptable as emphasized by the typical emails I received from clinicians:
"My patients are still coming on time and expect the high quality care they normally receive. They also want it in a timely manner. Telling them the computer system is down is not an acceptable answer to them. Having an electronic health care record is vital but when we as physicians rely on it and when it is not available, it leads to gaps in care."
"Any idea how long we will be down? I am at the point where I may cancel my office for the rest of the day as I cannot provide adequate care without access to electronic records."
In 2013, we've become dependent on technology and any downtime procedures seem insufficient.
2. The burden of regulation is much different in 2013. Meaningful Use, the Affordable Care Act, ICD10, the HIPAA Omnibus rule, and the Physician's Quality Reporting System did not exist in 2002. There is a sense now that clinicians cannot get through each day unless every tool and process, especially IT related, is working perfectly.
Add downtime/slowness and the camel's back is broken.
3. Society, in general, has more anxiety and less optimism. Competition for scarce resources translates into less flexibility, impatience, and lack of a long-term perspective.
4. The failure modes of technology in 2013 are more subtle and are harder to anticipate.
In 2002, networking was simple. Servers were physical. Storage was physical. Today, networks are multi-layered. Servers are virtual. Storage is virtual. More moving parts and more complexity lead to more capabilities but when failure occurs, it takes a multi-disciplinary team to diagnose and treat it.
5. Users are more savvy. Here's another email:
"Although I was profoundly impacted by today's events as a PCP trying to see 21 patients, I understand how difficult it is to balance all that goes into making a decision with a vendor on hardware/software maintenance. However, I was responsible for this for a large private group on very sophisticated IT, and I would urge you to consider doing future maintenance and upgrade projects starting on Friday nights, so as to have as little impact as possible on ambulatory patient care."
My experience with last week's event will shape the way I think about future communications for any IT related issues. Expectations are higher, tolerance is lower, and clinician stress is overwhelming. No data was lost, no patient harm occurred, and the entire event lasted a few hours, not a few days. However, it will take months of perfection to regain the trust of my stakeholders.
It's been 10 years since we had to use downtime procedures. We'll continue to reduce single points of failure and remove complexity, reducing the potential for downtime. As a clinician I know that reliability, security, and usability are critical. As a CIO I know how hard this is to deliver every day.
Building Unity Farm - Scenes of Summer
Unity Farm is at the peak of Summer. Everything is in bloom, the forest is bursting with wildlife, and all our outdoor activities are in full swing as we finish creation of our growing areas before we retreat inside for 6 months of winter. Here are a few photos with the scenes of Summer at Unity Farm.
1. Afternoon thunderstorms pop up during the hot and humid weather. They skies are filled with billowing clouds that dwarf the barn and paddocks.
2. The animals cling to their barn fans, run through the sprinklers and enjoy an afternoon snack of chilled romaine lettuce to keep cool
3. In the stream, Muskrat Susie and Muskrat Sam whirl and twirl among the reeds. (I know the song is awful)
4. Mom and Dad proudly walk our country lane with their new fawn
5. Guinea fowl build nests of 20-30 eggs in the deepest part of our fern forests
6. The Great Pyrenees enjoy playing in the shade with their new ball toy
7. The bees are storing honey for the winter. Here's a closeup of the queen from one of our 8 hives
8. The orchard grass has gone to seed and needs mowing . I maintain the orchard with a push mower and a trimmer for more delicate edge work. Here's a view of the mowing in progress and the finished result.
9. Ground hogs (also know as Woodchucks) nibble at the grass in the meadow.
10. Garter snakes sun themselves on the rocks in the garden
1. Afternoon thunderstorms pop up during the hot and humid weather. They skies are filled with billowing clouds that dwarf the barn and paddocks.
2. The animals cling to their barn fans, run through the sprinklers and enjoy an afternoon snack of chilled romaine lettuce to keep cool
3. In the stream, Muskrat Susie and Muskrat Sam whirl and twirl among the reeds. (I know the song is awful)
4. Mom and Dad proudly walk our country lane with their new fawn
5. Guinea fowl build nests of 20-30 eggs in the deepest part of our fern forests
6. The Great Pyrenees enjoy playing in the shade with their new ball toy
7. The bees are storing honey for the winter. Here's a closeup of the queen from one of our 8 hives
8. The orchard grass has gone to seed and needs mowing . I maintain the orchard with a push mower and a trimmer for more delicate edge work. Here's a view of the mowing in progress and the finished result.
9. Ground hogs (also know as Woodchucks) nibble at the grass in the meadow.
10. Garter snakes sun themselves on the rocks in the garden
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