Yoga for Menopause: Fatigue

by Nina

Rose Light by Melina Meza

When I was going through perimenopause, the worst symptom I had was fatigue attacks. Although fatigue or exhaustion is a classic symptom of perimenopause, I'm pretty sure I made up the term "fatigue attack" because I needed a special term for how it felt to me. I'm a pretty energetic person who gets a lot of things done in a given day, and my yoga practice during that time was quite athletic. But during that period, once in a while, I'd suddenly feel so drained of all energy that all I wanted to do was collapse into a puddle on the floor. There was something essentially different about these hormonally based episodes of fatigue than normal tiredness, and I remembered that same feeling of utter exhaustion from my pregnancies (although those were combined with nausea). So I knew it wasn't something I could fight with energizing poses, such as backbends or sun salutations. Fortunately, I got some guidance from two different senior teachers, Rodney Yee and Patricia Walden, who both helped me figure out a good way to practice when I was feeling that way.

When I first talked with Rodney about a fatigue practice, he came up with a sequence of supported inverted poses (see Just In Time for the Holidays: Inverted Poses). However, the first pose in the sequence was Downward-Facing Dog with head support (traditionally the beginning pose in a supported inverted pose practice), and I complained to him (whined?) that when I was feeling exhausted, that pose felt like to much. So he changed the sequence to start with a long Legs Up pose (Viparita Karani) so I could have a nice rest to start and then move on to more active inversions. That was a revelation to me who had only done that pose at the end of a practice. Learning I could rest at the beginning of my practice instead of the end—that I could break a rule that wasn't even a really rule— was a revelation. I started to realize I had a lot more freedom to adapt my practice to my particular needs that I had known. And practicing was a good way to get through a fatigue attack and did leave me feeling refreshed.

Later I took a workshop from Patricia Walden on Yoga for Menopause. She, too, recommended a combination of restorative poses and supported inversions. Eventually, when the book she wrote with Linda Sparrow, The Woman's Book of Yoga and Health, was published, I started to practice her menopause fatigue practice on a regular basis. This sequence is quite long and some of the poses may not appropriate for many of you, but I'll list all the poses here just in case.

1. Supported Reclined Cobbler's pose (Supta Baddha Konasana)
2. Supported Seated Forward Bend (Paschimottanasana)
3. Supported One-Legged Forward Bend (Janu Sirsasana)
4. Simple Seated Twist (Bharadvajasana)
5. Downward-Facing Dog with head support (Adho Mukha Svanasana)
6. Standing Forward Bend with head support (Uttanasana)
7. Headstand (Sirsasana)
8. Inverted Staff pose (backbend in a chair) (Viparita Dandasana)
9. Chair Shoulderstand (Sarvangasana)
10. Half Plow pose (Plow pose with chair) (Arda Halasana)
11. Supported Straight Leg Bridge pose (Setu Bandha Sarvagasana)
12. Legs Up the Wall pose (with variations) (Viparita Karani)
13. Relaxation pose (Savasana)

Regardless of whether you try this sequence or not, it's worthwhile to look at the strategy behind it. It begins with Supported Reclined Cobber's pose (Supta Baddha Konasana), which is a very restful and relaxing pose. Next are a couple of supported seated forward bends, which are also quieting and restful but a bit more active than the first pose. The simple seated twist is even more active, and definitely stimulating. So now, after having a rest and being a bit energized, you're ready for the more strenuous poses: Downward-Facing Dog with head support, Standing Forward Bend with head support, Headstand, and Inverted Staff pose (backbend in a chair). From there, with the Chair Shoulderstand, Half Plow pose, Supported Straight Leg Bridge pose, and Legs Up the Wall pose, you are moving into the quieting, soothing supported inversions, ending with the most restful of the group. You are also getting a balanced asana practice, with a combination of forward bends, backbends, twists, and inverted poses. (I should say this my analysis of the sequence, not Patricia's.)

As with any sequence, you could shorten this sequence by leaving out certain poses (especially if there are ones you don't normally practice) but still keep the remaining poses in the same order. Or, you could come up with a sequence of your own that combines restorative and supported inverted poses in a way that allows you to rest in the beginning, move toward more active poses, and then rest again at the end. The important thing is to acknowledge your fatigue, and adapt your practice to your current condition, thinking outside the box as needed. And, remember, doing even just one pose (such as Reclined Cobbler's pose or Legs Up the Wall pose) will very likely make you feel better than doing nothing.

Naturally, if you aren't going through periomenopause or menopause (or aren't a woman!), you can still do a practice like this whenever you feel exhausted.

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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.

"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."

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.

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Forbes Magazine Gives Yoga a Thumb$ Up

by Baxter

View From Above by Melina Meza

I love it when capitalist magazines find something good to say about yoga, even if it is how it is making someone lots of money. But in this case, Forbes says yoga might save the US trillions of dollars in lost productivity for our economy. How so, you ask? Why, for a start, by reducing the dropout rate from high schools in this country, rates that shockingly range from 30% in most places to over 50% in our urban “war zones.” (I call them war zones because of the continual violent backdrop that these children are subjected to day in and day out; where just walking to and from school, let alone being in school, is a constant cause for anxiety and worry about getting hurt or killed.)

What was a delight to see is one of the featured yoga experts quoted frequently in the article, BK Bose, in whose Niroga Institute in Berkeley, CA, I have had the great pleasure of teaching for the past several years. Bose, who started his career as a software engineer in the high tech industry in Silicon Valley, has more recently focused his work on bringing yoga to under-served communities, and training teachers to work with these special populations. These include classes at the Alameda County Juvenile Hall, low-income public schools and low-income senior centers, to name just a few. His work, as with most small operations around the country, is done as a non-profit venture. Even on its smaller scale, the results of the yoga classes are significant.

And after all, if we can influence the health of our youngest at an early age, that should lead to a longer, healthier life as they age (and, of course, many of our readers have school-aged children). The key underlying factor that Bose identifies as the culprit in so many of the challenges our young face is chronic stress. We have written on many occasions about the ways in which yoga can help us deal with stress. But what about in our kids, and in the growing number of kids that have to deal with gangs, substance abuse, and crime in their neighborhoods? This adds a whole new twist on doing straight up mindfulness techniques. These techniques can work quite well for children who don’t have the kinds of violent communities that Bose’s programs work with, as you will see below.

For me, as I read the article, I found one concept that comes from mind-body research defined in a new way that I could relate to from my own yoga teaching.  I often refer to the mind’s background chatter as “monkey mind” or “restless mind,” and the tendency is for this kind of thinking to have a background feeling of anxiety or stress associated with it. The following paragraph from the Forbes article talks about what mindfulness practices do to the brain, including the new phraseology “default mode network (DMN)” which I find confirming of my own observations:  

“In 2011, a Harvard study showed that mindfulness is linked to increased gray matter density in certain cortical areas, including the prefrontal cortex and regions involved in self-referential thoughts and emotion regulation. There seems to be a strong connection between mindfulness and the brain machinery involved in self-regulation. Other work has shown mindfulness to be linked to relative de-activation of the default mode network (DMN), the brain system that’s active during mind-wandering and self-referential “worry” thoughts, which are generally stressful in nature.”

Mindfulness practices, then, help us change the way we are thinking, or at least the way we are focusing our minds, which changes our stress response. For a young person, this might equate to changed behavior, in which he or she has more control over emotional reactions that might lead to trouble. Bose, however, notes that in his students who live in violent communities and are more often directly or indirectly victims of trauma, mindfulness is not going to work.  As the article points out:

“This is all well and good, Bose adds, but there’s an obvious caveat. When they’re in the midst of stress and trauma, few kids have the ability to sit still enough to take part in a sitting practice. “If you’re not ready to sit in classroom,” says Bose, “you’re not ready to do sitting meditation. If you have drugs and gangs and violence all around you, you simply can’t sit still. Teachers tell us that they often yell at kids 100 times a day to sit and pay attention. It doesn’t work. And to ask them to do this in the context of meditation can have a worse-than-neutral effect – it could be disastrous.”

He says that you have to go beyond mind-body research to trauma research, which tells us that physical activity can help the brain deal with stress and trauma.

“Trauma research tell us that we hold trauma in our bodies… Neuroscience says mindfulness; trauma research says movement. All of the sudden you’ve got moving meditation or mindfulness in motion. Mindfulness alone isn’t going to cut it for these kids.”

Even for adults who carry a lot of anxious energy stored up in their bodies, we here at Yoga for Healthy Aging have advocated for the necessity of movement practices, sometimes more vigorous yoga styles, as an initial stage in leading to deeper relaxation and stress reduction in your daily practice. Turns out to be true for kids with trauma, too.

The take-away from this Forbes exposure of yoga to a larger audience in the US and for us yogis here as well is that it may prove invaluable to teach young and old alike to do yoga, combining active asana and quieter mindfulness practices for maximum benefit. And that it would be a good idea to change policy on a national level to fund such ventures, so everyone at least has access to trying yoga, to see if it works for them. What an interesting, and possibly wonderful, world that could be! 

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Yoga and Menopause: An Overview

by Shari

Mushroom in Winter by Melina Meza

Nina and I were talking a while back and we realized that we hadn't yet written any posts on menopause. Well, considering that this physiological episode is a major event in every woman's life, we thought it was about time to take this on, and decided that I should start the ball rolling so to speak. Although each woman’s experience of menopause is very personal and individual, there are certain similarities that we all experience, including the end of the ability to give birth! Now this is not to imply that all woman make the decision to become pregnant and raise a child, but the physiological ability to become pregnant is age-related.

To begin our exploration of menopause, I read the book Yoga and the Wisdom of Menopause. A Guide to Physical, Emotional and Spiritual Health at Midlife and Beyond by Suza Francina. This book was published in 2003 but the information it contains is still pertinent. It provides good background information about what menopause is, and how yoga can be applied in all the stages that lead up to menopause as well as during menopause to help alleviate some of the more common issues that woman have to deal with. The usage of yoga was the unifying theme throughout the book.

Moving to specifics, I'll start by defining what menopause is and how you know you are in it. "Meno" means "month" in Greek and "pause" comes from the Greek "pausis" for stop. So menopause is the cessation of menstrual periods, an end to the monthly cycle. There are three stages:

1. The first stage is perimenopause (“pre-menopause"), when the change in hormonal functions leading up to menopause occur. Typically perimenopuase begins around age 40 (but remember this is a rough estimate) but can begin in one’s 30’s. This stage typically lasts around 5 years, but sometimes lasts for 15 years. In perimenopause women may notice changes in their menses where they are lighter and longer to heavier and more frequent. There are many hormone fluctuations and sometimes this time is called “puberty in reverse”
2. The second stage is menopause itself because the menses stop. Menopause is considered official 12 months after the last period. The average age of women whose menstrual periods have stopped is 52. Though a woman’s period has stopped, it doesn’t mean that the hormonal levels are stabilized and this period is categorized by emotional shifts, hot flashes, hot surges or flushes.
3. The final stage, which lasts the remainder of a woman’s life, is post-menopause when the woman’s body has adjusted to its hormone levels.

Most often when we think and talk about menopause, we focus on the physical discomforts, emotional roller coaster ride and weight redistribution in our bodies. But it is a time where we all are learning to adjust to our physical changes, energy changes, and mental challenges. Now Nina has written extensively in the past about emotional health and moods as well as management of depression through the usage of yoga. All of her recommendations can be applied very directly to the challenges some women experience during the stages of menopause.

My particular interest in reading this book was usage of yoga and its effect on the endocrine system and easing menopausal symptoms, especially the management of stress. The book provides illustrations of restorative poses to counter the stresses of a body adjusting to widely fluctuating hormonal levels. Supported Relaxation pose (Savasana), Supported Child's pose (Balasana), Supported Backbends with a bolster, Legs Up the Wall pose (Viparita Karani), and Supported Reclined Cobbler's pose (Supta Baddha Konasana) are highlighted repeatedly in personal vignettes as a prescription for health. (not necessarily in this order). Supported standing poses, inversions, and twists are also recommended, with the woman using a wall or a chair to prevent overly exhausting herself during asana practice. A guiding principle that is cycled back over and over again is that our practice of yoga changes as our body changes. This is not just due to physical aches and pains or the limitations in mobility, energy or strength but in how our intuitive self begins to guide us more in our asana practice.

What I liked most about this book was its celebration of the cycles of a woman’s life. Throughout the book there is joy about entering into an initiation that all women are a part of. The usage of asana is as a guiding tool to help us navigate this unknown territory. The author presents her book as a way to nourish one’s soul through the practice of asana.

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Friday Q&A: One Leg Shorter than the Other

Q: I recently learned that my back pain for two years now (surgery recommended) is due to my right leg being shorter (2nd opinion from another back surgeon). My right shoulder and right hip are higher than the left side. Is there a yoga exercise or two that could help me correct this and alleviate the back lumbar pain?

Upper Leg Bone

A: This is a great question, and quite a common finding for many people: having one leg shorter than the other. And as your second surgeon seemed to point out, the presence of one leg shorter than another and low back pain in the same person could be related. Most individuals have a small difference in their leg lengths. Because this is so common, if the difference between right and left is small enough, it does not typically contribute to lower back pain. This is usually the case for people if their leg length difference is less than a ¼ inch. (On a personal note, when I went to my chiropractor recently for a shoulder/neck issue, she mentioned that I had a slight leg length discrepancy that I had never known about. And it turns out I have occasional lower back and sacral pain!)

When you get leg lengths that differ greater than 1/4 inch, that is when it can contribute to lower back pain. And if you have a leg length difference of greater than ½ inch, you are six times more likely to have an episode of lower back pain. That is pretty significant!

For those not familiar with Leg Length Discrepancies (LLD), I’d like to give a little more background. The two main causes of LLD are: 1) poor alignment of the pelvis and 2) having one leg that is structurally longer than the other. Other potential causes include an injury (such as a fracture), bone disease, bone tumors, congenital problems (present at birth) or neuromuscular problems, but these are much less common. Regardless of the reason, your body wants to be symmetrical and will do its best to compensate for the length difference. Certain other conditions can be present along with leg length discrepancy, such as scoliosis, lumbar herniated discs, pelvic torque, greater trochanteric bursitis, hip arthritis, piriformis syndrome, patellofemoral syndrome and foot pronation. I’ve written about a few of these other conditions elsewhere in our blog. But if you have one of these other diagnoses, you may want to ask your doctor to check you for a leg length discrepancy.

The signs and symptoms of LLD can include:

• one leg being obviously longer than the other (mine was not obvious to me!)

• affected posture, especially secondary scoliosis or one shoulder higher than other (and scoliosis could lead to secondary LLD)

• problems with gait
• pain in the lower back, but also hip, ankle or knee

Lower Leg Bones

As mentioned above, LLDs can be the result of legs actually being of different lengths or the pelvis being torqued and tipped. This leads to two ways of classifying LLD:  a structural leg length discrepancy or a functional leg length discrepancy. A structural leg length discrepancy is a hereditary circumstance where one leg is simply longer than the other leg. This is determined if your pelvis and sacroiliac joints are symmetrical and the leg length is simply due to one leg truly being longer than the other, say via an X-ray.  Functional leg length discrepancy is diagnosed when there is a torsion or pelvic rotation, commonly a sacroiliac (SI) joint dysfunction, which causes one leg to function as though it is longer or shorter than the other. In order to determine if a true structural discrepancy exists, a physical therapist must treat the pelvis and return it to a neutral position before measuring for the leg length discrepancy. Once the pelvis is symmetrical, if the leg length discrepancy goes away it is classified as functional.  If it remains and has a measurable difference, it is a structural leg length discrepancy.  So our questioner of the week may want to begin by finding out if she has a structural or functional LLD, before deciding how yoga can be applied.

How does your western MD and Physical Therapist usually address leg length discrepancy? Structural leg length discrepancy can be treated with a heel lift in the shorter leg’s shoe. You want to let your physical therapist determine the height of the lift, since it is determined by how much lift is needed to restore proper biomechanics in the pelvis and lower back. I know of at least one student of mine who wears a thin-soled shoe on one foot during her yoga practice, as well as a heel lift in one shoe outside of yoga class. This seems to compensate and correct her imbalance and allows her to fully participate in all of her standing poses, especially the symmetrical ones such as Mountain pose (Tadasana), Powerful pose (Utkatasana) and Standing Forward Bend (Uttanasana). In rare instances, surgery may be recommended to either shorten or lengthen the limb. This is always accompanied by a course of physical therapy, which helps to stretch muscles and maintain joint flexibility, which is something yoga asana could compliment.

For a functional leg length discrepancy where the real issue is the tipping and torque of the pelvis, no heel lift is required. Instead, a physical therapist would use proper manual therapy techniques and specific therapeutic exercise to treat and normalize pelvic and lower extremity compensations.  In yoga styles where alignment is a main focus of the poses (such Iyengar and Anusara), the asana practice could function to restore pelvic evenness. Once the pelvis is even, you should re-measure your legs. If they are pretty close to even, your leg length discrepancy was functional; if not, you could have an underlying structural leg length discrepancy that might still require a heel lift.  I wish there were one or two poses I could recommend without knowing all this student’s particulars, but that is not possible without an more thorough history and physical exam.  In general, a well-balanced yoga practice that includes reclining, seated, standing and some easy inverted poses could serve as a good starting point. But since low back pain is present, I’d recommend looking for a specialty class on yoga for back pain, where you are more likely to have a teacher experienced enough to give you some special guidance.


—Baxter

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More Love for Baroreceptors: Supporting Your Head in Restorative Poses

by Nina

When I first starting taking yoga, I was confused about why my teachers were always rushing put to a folded blanket under my head when I was lying on my back. Something about the position of my head when I was lying on the floor was driving them crazy, but what was it? And why was it such a problem?

Later I learned that they were adding this support because, when my head was flat on the floor, due to tightness in my shoulders, my neck was arching up and back and my chin was tipping away from my chest. Putting the folded blanket under my head allowed me lie with my chin pointing toward my chest like this:

This was considered to be the proper--and healthy—position for the head in supine poses. So I went along with it. But secretly I continued to wonder why. In case you have already noticed, I'm like that—always wanting to know the whys as well as the hows, always wanting to dig a bit deeper. Which is probably why I ended up as a yoga blogger, but I digress.

Anyway, it was only when I learned about baroreceptors that I found a satisfactory explanation. As I mentioned yesterday (see Why You Should Love Your Baroreceptors), when your neck is slightly flexed (the position when your chin is pointing toward your chest), the position puts some pressure on the baroreceptors in your carotid arteries. And this pressure can cause the same response as an inverted pose does on your nervous system—switching you from fight or flight to the relaxation response. The opposite neck position with your neck in extension (a backbend position with your chin tipping away from your chest) can have the opposite effective, stimulating your nervous system.

Of course, this understanding of the role of baroreceptors in yoga poses is very recent. In fact, the understanding of the role in regulating blood pressure in general is pretty recent as well. So the yoga teachers, like B.K.S. Iyengar, who developed restorative yoga discovered the best position for the head through personal observation, not science. (That says a lot about personal observation, doesn't it?) Interestingly, the head position Jalandara Bandha, with neck flexed and chin pointing down toward the chest, used in seated poses for pranayama, which is much older than restorative yoga, was probably adopted for the same reasons. Yoga practitioners noticed that head position enhanced the quieting effect of the practice.

I thought I'd tell you all this not just because you might not have made this connection on your own, but because I also realized there might be some people out there who don't have teachers running to put a folded blanket under their heads every time they lie in a supine restorative pose. So that's both the how and why for you. The how is that when you lie on your back, if your chin does not easily point down toward your chest, always add some support under your head. The why is that having your chin pointing down toward your chest will enhance your relaxation due to slight pressure on your baroreceptors.

Long live head support!

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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

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The Era of Epic

In the Boston marketplace, Partners Healthcare is is replacing 30 years of self developed software with Epic.   Boston Medical Center is replacing Eclipsys (Allscripts) with Epic.   Lahey Clinic is replacing Meditech/Allscripts with Epic.  Cambridge Health Alliance and Atrius already run Epic.   Rumors abound that others are in Eastern Massachusetts are considering Epic.  Why has Epic gained such momentum over the past few years?   Watching the implementations around me, here are a few observations

1.  Epic sells software, but more importantly it has perfected a methodology to gain clinician buy in to adopt a single configuration of a single product.   Although there are a few clinician CIOs, most IT senior management teams have difficulty motivating clinicians to standardize work.  Epic's project methodology establishes the governance, the processes, and the staffing to accomplish what many administrations cannot do on their own.

2.  Epic eases the burden of demand management.   Every day, clinicians ask me for innovations because they know our self-built, cloud hosted, mobile friendly core clinical systems are limited only by our imagination.   Further, they know that we integrate department specific niche applications very well, so best of breed or best of suite is still a possibility. Demand for automation is infinite but supply is always limited.   My governance committees balance requests with scope, time, and resources.   It takes a great deal of effort and political capital.   With Epic, demand is more easily managed by noting that desired features and functions depend on Epic's release schedule.   It's not under IT control.

3.  It's a safe bet for Meaningful Use Stage 2.   Epic has a strong track record of providing products and the change management required to help hospital and professionals achieve meaningful use.  There's no meaningful use certification or meaningful use related product functionality risk.

4.  No one got fired by buying Epic.   At the moment, buying Epic is the popular thing to do.   Just as the axiom of purchasing agents made IBM a safe selection,   the brand awareness of Epic has made it a safe choice for hospital senior management.   It does rely on 1990's era client server technology delivered via terminal services that require significant staffing to support, but purchasers overlook this fact because Epic is seen in some markets as a competitive advantage to attract and retain doctors.

5.  Most significantly, the industry pendulum has swung from best of breed/deep clinical functionality to the need for integration.   Certainly Epic has many features and overall is a good product.   It has few competitors, although Meditech and Cerner may provide a lower total cost of ownership which can be a deciding factor for some customers.   There are niche products that provide superior features for a department or specific workflow.   However,  many hospital senior managers see that Accountable Care/global capitated risk depends upon maintaining continuous wellness not  treating episodic illness, so a fully integrated record for all aspects of a patient care at all sites seems desirable.  In my experience, hospitals are now willing to give up functionality so that they can achieve the integration they believe is needed for care management and population health.

Beth Israel Deaconess builds and buys systems. I continue to believe that clinicians building core components of EHRs for clinicians using a cloud-hosted, thin client, mobile friendly, highly interoperable approach offers lower cost, faster innovation, and strategic advantage to BIDMC.  We may be the last shop in healthcare building our own software and it's one of those unique aspects of our culture that makes BIDMC so appealing.

The next few years will be interesting to watch.   Will a competitor to Epic emerge with agile, cloud hosted, thin client features such as Athenahealth?   Will Epic's total cost of ownership become an issue for struggling hospitals?   Will the fact that Epic uses Visual Basic and has been slow to adopt mobile and web-based approaches provide to be a liability?

Or alternatively, will BIDMC and Children's hospital be the last academic medical centers in Eastern Massachusetts that have not replaced their entire application suite with Epic?   There's a famous scene at the end of the classic film Invasion of the Body Snatchers, which depicts the last holdout from the alien invasion becoming a pod person himself.  At times, in the era of Epic, I feel that screams to join the Epic bandwagon are directed at me.

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Image Exchange

Last week, the Clinical Operations Workgroup of the HIT Standards Committee held its third hearing on image exchange, seeking testimony from Hamid Tabatabaie, CEO of LifeImage and Michael Baglio, CTO of LifeImage.

He made several important points
1.  We should think of image exchange as having two major categories - local and long distance.    DICOM works well for modality to PACS connectivity within an enterprise (local).   DICOM was never designed for internet-based cross organizational image sharing.   DICOM images tend to be large, including a vast amount of metadata with every image object in a study.    DICOM was also never designed to work well with the kind of firewalls, load balancers, and network security appliances we have today.

2.  Two image exchange architectures have been used in the marketplace to date, which Hamid called "iTunes" and "Napster",  classifications first suggested by Dr. Keith Dreyer.

iTunes refers to the centralization of images into a single repository or what a appears to be single repository - it may actually be a clearinghouse to other image stores, but the user never knows that.   Query/response transactions against this central repository can be straightforward, using standards such as Blue Button Plus/Direct for share, access, download.

Napster refers to a decentralized, federated model in which images are not placed in a single repository -    an index of images and their location is all that is centralized.   Typically, query/response is done with standards such as XDS-i.   XDS itself was never designed for image exchange and is incomplete.  It can be challenging to search for a single exam on a known date of a known modality type.

3. Current standards do not include any privacy metadata and security is not built in.  Future standards should enable applications to restrict image flows based on consent/patient preferences.

4.  We need a web friendly method for visualization that does not require the download of a proprietary viewer, one that is often operating system specific.   Consumers should be able to view thumbnails of images on a smartphone, tablet, or the device of their choosing without special software.   If the full DICOM object is needed (patient mediated provider to provider image exchange), download and transmission should be enabled using standards such as REST, OAUTH2/OpenID, and secure email.

5.  Hamid made a forward looking statement that should be carefully considered as we plan the lifecycle of existing Radiology Information Systems (RIS) and Picture Archiving and Communication Systems (PACS) systems.   He is seeing EHR features expand to cover many aspects of RIS workflow.   If scheduling, image viewing, report construction with templates/front end voice recognition, and easy exchange of reports with clinicians are supported by the EHR, maybe radiologists (some of which want to qualify for meaningful use payments) will start using increasingly capable EHRs instead of RIS.   Vendor neutral archives (VNA) which store images of all "-ologies"  and enable easy search and retrieval may replace PACS.   Imagine 5 to 10 years from now when RIS/PACS no longer exists and is replaced by EHR, HIE,  and VNA.   Interesting possibility.


Great testimony.    In the past when I've suggested DICOM is not ideal for internet-based multi-organizational exchange, I've been criticized.   In the past when I've suggested that DICOM has issues of vendor-specific proprietary metadata extensions, cumbersome viewers, and heavy payloads, I've been challenged.   It's refreshing to hear from someone doing the hard work of high volume image sharing that current standards not ideal.  We need new approaches to move payloads efficiently on the internet, view images via web-browsers, facilitate easy searching, support security, and enable multiple provider/patient/group sharing use cases.

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