Building Unity Farm - Reflections on our First Winter

The third week of January is always the coldest time in New England.    Mt Washington was -70F and Unity Farm was 1.4F 

When we began this season I had no idea how to keep the animals happy and healthy in near zero temperatures.    We've learned a great deal and thus far, everything has worked.

Chickens and Guinea Fowl - I've written about keeping warm in New England,  highlighting that convective, conductive, and radiated heat loss need to be controlled.    For poultry, a dry, wind free coop with off ground roosting helps a great deal.   Our chicken breeds are very cold hardy due to their small combs and waddles.   However, to completely guard against frostbite, we added 150 watt sealed heating panels to the roof and baseboard of the coop (photo below).   These are thermostatically controlled and go on at 35F, off at 45F    They've worked perfectly, ensuing the coop is 10-15 degrees warmer than the outside temperature.     Keeping water supplies liquid at zero F requires planning.   For the chickens, their hanging bucket waterer now has a submersible thermostat controlled heater (photo to the right).    For the guinea fowl, their standalone waterer sits on a thermostat controlled heat plate.     In very cold weather, the guineas rarely leave the coop, enjoying the food, water, and warmth of their gently heated home.     I did have to wire the coop with tamper-proof (beak proof), weather resistant (from chicken droppings) outlets and rugged 14 gauge romex wire.   Everything has worked without a hitch.

Dogs - The Great Pyrenees have double coats and really enjoy snow and ice.   They eat the "popsicles" from the ice that falls from the barn roof.   Just as with the chickens, keeping dogs out of the wind and wet weather is important.   We've created spaces for them in the hayloft - they curl up among the bales, staying warm on blustery winter nights.  Also, we use a thermostatically controlled heated bucket to keep their water liquid.

Alpaca/Llama - The camelids seem impervious to cold but do not like the wind.   We created rubber floored stalls with sliding doors that provide a wind and rain barrier.    Their water buckets are heated.   We feed them hay with a high percentage of alfalfa (extra calories) on cold days.    We feed each of them a cup of high energy grain in the morning and evening of each winter day.  We supplement their diet with beet pulp. Shoveling manure during weeks that never rise about freezing has proven to be a challenge.   I can use a wrecking bar, pick, or hammer to break up manure, but I've found it more practical to wait until a thaw day to shovel.

The combination of appropriate housing, low wattage heaters, and water management, has proven to me that winter on Unity Farm will pass without any animal health and well-being issues.

The Retirement of a Healthcare IT Legend

On Monday, I had the privilege of attending the retirement luncheon for G. Octo Barnett, the founder of the MGH Laboratory of Computer Science (LCS) and the inventor of the MUMPS (Massachusetts General Hospital Utility Multi-programming system).

Henry Chueh, Division Chief of LCS, served as master of ceremonies.

The attendees were the luminaries in the field of medical informatics - Donald Lindberg, Randy Miller, Clem MacDonald, Charlie Safran, Paul Egerman, Rita Zielstorff, Albert Mulley, Howard Bleich, Warner Slack, Chris Cimino, Peter Beaman and many more.

Everyone told stories about Octo's achievements inside and outside the lab.

In many ways, he is the catalyst that spawned companies such as Meditech, IDX, Epic, Intersystems, and many others.

Octo himself is a humble man and offered his sincere thanks to everyone who has worked with him over his 50+ year career.

He's a great man whose contribution to the healthcare IT industry is overwhelming.   I've said that in life the most important thing is to make a difference.   Octo made a difference.

The Health Information Exchange Hearing

Today in Washington, the Standards and Policy Committees met in joint session to take testimony from expert stakeholders about health information exchange.

Farzad Mostashari, National Coordinator, introduced the day, noting that we've made great strides since the founding of HL7 in 1987 and the creation of ONC in 2004, but there is more work to do.  The includes early successes, a discussion of barriers/challenges, the elements needed to ensure trust, and the role of consumers.   The hope is that the foundation laid by Meaningful Use stage 2 will enable reduced costs (and reduced vendor pricing for interfaces), increased benefit, and privacy protections that have not been historically possible.

Micky Tripathi, CEO of the Massachusetts eHealth Collaborative provided an overview of the  current landscape in his presentation, The State of Health Information Exchange.  He described HIE 1.0 as the noun and HIE 2.0 as the verb with many models  (in order of increasing level of external coordination needed):

Point to patient
Point to point
Vendor specific
Transaction specific national level
Enterprise level HIE organizations
State and regional collaboratives
National level collaborative

Next, I moderated a panel, Health Information Exchange Enabling Healthcare Transformation, describing the technology and policies which have enabled successful health information exchanges.   The major lesson learned was workflow and business value are even more important enablers than technology.

We heard from
Michael Lee, Atrius Health
Sandy Seltzer, Camden Coalition
Keith Hepp, HealthBridge
John Blair, Hudson Valley Initiative
Karen VanWagner, Plus ACO/North Texas Specialty Physicians

Next Paul Tang moderated a panel, Technical and Business Barriers and Opportunities, which concluded that meaningful use stage 2 significant reduced technology and policy barriers by constraining optionality in standards and aligning incentives to exchange data.  We heard from

John Halamka, Beth Israel Deaconess Medical Center
David Horrocks, CRISP
Bill Spooner, Sharp
Tone Southerland, Greenway

After lunch, I moderated a panel, Governance Barriers and Opportunities, which focused on governance and trust fabric efforts necessary to ensure authentication and authorization of participants in health information exchange.   We heard from

David Kibbe, Direct Trust
Christopher Alban, Epic
Sid Thornton, Care Connectivity Consortium
Michael Matthews, Healtheway

Finally, Paul Tang moderated a panel, Consumer-Mediated Exchange, which emphasized the importance of provider-patient as well as provider-provider health information exchange using the Direct standards.   We heard from

Jeff Donnell, NoMoreClipboard
Mary Anne Sterling, Sterling Health
Neal Patterson, Cerner
Alan Blaustein, Care Planners

Paul Tang summarized the day and we agreed that the robust discussion will inform the work plans of the policy and standards committees as we all work hard to increase the volume and usefulness of health information exchange throughout the country.

Building Unity Farm - Creating an Animal Community

On our journey to become small scale farmers, we've visited many New England farms, orchards, and CSAs.   We've had 3 major lessons learned:

*Create the infrastructure you need before adding animals to the property
*Do not acquire more animals than you can manage
*Ensure the animals are compatible with each other and that you'll have a healthy community with symbiotic relationships

Infrastructure - many farms we visited had inadequate or temporary fencing, created or patched after an animal escaped or was injured trying.    Often there was little advance thought to manure management, workflow, and access for humans and machines.    In laying out our fences we placed gates on every edge and sized them based on the need for animal and equipment flow patterns.   The inputs and outputs of food, water, and manure formed the requirements for design before anything was built.

Number of animals - Today we have 50 animals, which enables us to give personal attention to every one.   Each night we examine all our chickens and guinea fowl to ensure they are healthy.   Every day the Great Pyrenees get two runs around the forest and orchard.    For alpacas and llamas,  we trim their toenails, clean their ears, examine their skin, weigh, and measure their body scores every month. This month we found a small ear abscess on one of the alpacas and performed an incision and drainage to accelerate healing.   My wife and I, plus the monthly help of the original alpaca breeder,  constitute enough resources to give personalized attention to every animal.   Many farms we visited had sick, underweight, and overcrowded animals that exceeded the capacity of the farmers to care for them.

Community - we chose our animals carefully.   Our guard llama lived her entire life with alpacas and was familiar with guarding duties.   Our alpaca spent their entire lives together as a herd.   Our chickens were hatched together on the same day.   The guinea fowl were all part of the same flock.    The dogs have bloodlines from the same breeder and grew up together.    We were very careful to introduce the llama to the alpaca so that each had enough space to acclimate to each other.   We introduced the dogs one at a time to the alpaca, and separated the dogs from each other until they established a relationship through a fence.   The chickens and the guineas shared a two room coop for months until we opened the door and enabled them to interact.  They now roost with each other.

The end result has been a harmonious community at Unity Farm.  The photo above shows Shiro, our 83 pound Pyrenees puppy, sleeping with Stanley, our 106 pound alpaca "puppy".  The dogs and alpacas curl up together for warmth on cold winter days like today, when it's 6 degrees in the barn.

We're very satisfied with our community of animals and will be very judicious in adding more.   This spring and summer we are removing an old hot tub on the property and replacing it with a koi pond, engineered to stay partially unfrozen during the winter.   We may consider adding indian runner ducks 
once we have a small pond for them near the barnyard.

We will not add sheep or goats because they will bring unique diseases and parasites to the herd of llamas and alpacas.    Every expert we've spoken with has suggested that public health/population health management of barnyards is best when species diversity is limited.

That's our animal community.    Thus far, the citizens of Unity farm are thriving in it.

Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules

On January 17, HHS released the Final Rule entitled: Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules

It's 563 pages long and contains 7 themes:

Covered entities must ensure that they obtain satisfactory assurances required by the rules from their business associates, and business associates must do the same with regard to subcontractors, no matter how far 'down the chain' the information flow

Increases penalties to $1.5 million per year

Tightens limitations on the use of patient records for marketing

Prohibits the sale of patient information without a patient's consent.

Provides patients with a right to insist that a provider not share their patient-care records with their insurance company if that care is paid for by the patient out-of-pocket in full.

Requires entities with patient record breaches to assess the likelihood that the information could be accessed in determining whether they must notify individuals of the breach.

Adds patient-safety organizations, health information exchange organizations and e-prescribing gateways to a specific list of HIPAA business associates liable under the rule. It also includes as business associates certain vendors of personal health records, those that provide a PHR to patients “on behalf of a covered entity,” but excludes other PHR providers, such as those working on behalf of consumers.

Much of the final rule is a restatement of requirements in ARRA/HITECH and GINA.   Generally the recommendations are very reasonable.   One challenging aspect of the final rule is the provision that provides patients with a right to insist that a provider not share their patient-care records with their insurance company if that care is paid for by the patient out-of-pocket in full.   At present this will be technically challenging to implement.   For example, if a patient pays for their outpatient treatment in cash and an e-prescription is generated, how do we flag the prescription to ensure it does not flow into a Pharmacy Benefit Management database?   If an inpatient hospitalization is paid in cash, how do we prevent a nurse case manager working for a payer from seeing any data related to that care episode?  Such data segmentation needs metadata around each data element so that data flows can be selectively restricted.   A great goal but definitely a work in process for which no products nor standards exist.

In the workplan for FY13 that I presented at the January HIT Standards Committee meeting, I highlighted the need for our workgroups to study standards supporting data segmentation for privacy, so hopefully we'll close this gap in the next year and have products in the marketplace which support such controls by 2014.

I know that many groups are hard at work analyzing the new rule, so I look forward to their wisdom.   The rule's 563 pages are rich with detail.