Supporting the Living

My father died a month ago and I flew to Los Angeles this weekend to help my mother during the grieving process.

She's doing very well.

The death of a spouse (or father) can be traumatic to everyone involved.  The tasks that follow the funeral are numerous - wills/trusts are acted upon, accounts are closed/changed, credit cards are cancelled, insurance policies are claimed or revised, IRAs are transferred, and death certificates are circulated to every appropriate public and private organization that needs legal notification.

But there is much more to supporting the living than the financial and legal "to do" list.

The life tasks performed by two people must now be performed by one.

We all depend on friends, family, and life partners to support our activities in life.  This weekend was about empowering my mother to manage my father's tasks.

What are the some of those responsibilities that seem trivial but require specialized knowledge?

The sprinkler system/irrigation controller needs to be managed, ensuring the gardens receive the right amount of water as weather changes.

The security system and smoke alarms/carbon dioxide detectors need battery changes.

Printers need toner and paper.

Internet routers and wireless devices need resetting.

Plumbing, electrical, and painting tasks need to be managed.

Light bulbs need changing (and some ceiling fixtures can be very challenging to access)

Entire digital lives need to be maintained, merged or erased.

Many items throughout the house need to be recycled, removed, or stored.

Cars need to be serviced or sold

This weekend was about supporting the living as the grieving process evolves into planning for the future.

My mother and I took numerous trips to Home Depot, worked on all the maintenance tasks that had accumulated over the past month, and prepared her to be the steward of the house/everything in it.

I brought her an iPad and an AirPrint enabled printer to improve her access to media and communications.    We worked so closely on planning all aspects of her next stage of life that I'll have no problem supporting her via email, texts, and phone calls.

We both miss my father but know that we cannot bring him back.   My mother's resilience and willingness to learn are truly inspiring.    I'll be back to Los Angeles again in a few weeks when I lecture at Pri-Med in Anaheim, but I'm completely confident my mother will thrive in my absence.

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Thursday Building Unity Farm - Creating the Mushroom Farm

I recently wrote about the planning for our Shitake and Oyster mushroom farm.

 Last weekend we began to build it.

Using oak that we cleared during the orchard preparation process,  I cut 150 four foot logs and will cut 70 more next weekend.  A local farm hand and I moved them from the orchard to a shaded area under maple trees near the northern border of the farm property.   We created a log storage area between two old stone walls.

Next, I had to design the mushroom inoculation "assembly line".  The process of inoculating logs includes drilling 5/16 x 1.5 inch holes every 4 inches around the entire circumference of the log.   I used 7 inch wheels on 3 foot threaded rods to create a roller system for easy drilling around the entire log.   Once drilled, the log is rolled down the line to the next person who inserts sawdust spawn with a brass inoculator.   Finally, the log is rolled down to the end where melted cheese wax is applied to each hold to seal in the spawn and moisture.  The assembly line itself is created with eight 2x4s and Simpson tie down strapping to support logs up to 100 pounds.  

Once the logs are prepared - we'll do that May 11-12 and May 18-19, they'll be moved to the shade house , a 10x30 foot galvanized frame covered with 80% shade cloth.   Inside the shade house I created eleven 4x4 bases which will hold the 220 logs we plan to inoculate this year (11 different types of Shitake x 20 logs per type).

Over the next few weeks, I'll also add mist irrigation to the shade house to keep the ambient humidity at about 80%.

With advice from Leo Mondragon, an expert mushroom farmer at Forest Harvest  and 60 pounds of mushroom spawn from Field and Forest , we'll have our mushroom farm up and running by Memorial Day, at about the same time our 2 acre orchard is completed.    We'll expect our first harvest next Spring.

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A Massachusetts HIE Update

In the next few weeks, BIDMC will begin sending 50,000 patient encounter records per week through the state HIE (the MassHIWay) to our quality measurement service operated by the Massachusetts eHealth Collaborative.    Also in a few weeks, all the daily reportable lab, syndromic surveillance, and immunization data required by Meaningful Use Stage 2 will be sent to the Massachusetts Department of Public Health via the state HIE.

On Monday, the governance body of the state's healthcare IT activities, the Massachusetts HIT Council, met to discuss the next phase of our state HIE work - creating the technology and policy to support community wide "pull" of records with patient consent, not just the pushing of records from place to place that is required by Meaningful Use Stage 2.

There are tricky policy issues to resolve.   Does the substance abuse treatment data sharing regulation 42 CFR Part 2 apply to hospitals and doctors without substance abuse treatment programs?   How will the Massachusetts HIV consent requirement (opt in to view at each episode of care) be implemented electronically?  How will the new HIPAA Omnibus rule requiring restricted flow of self-pay encounters be implemented electronically?  

Here are the slides we used to describe the inputs from our technology, consumer, provider, and legal policy workgroups.

Our next step is to continue our adoption acceleration grant program and build transaction volume.   We expect the pace of adoption to grow exponentially as organizations prepare for Meaningful Use Stage 2 attestation and must exchange transition of care summaries for 10% of their patient visits.

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Commencement at Columbia University

I recently spoke at Columbia University to the graduates of their healthcare IT certificate program.    I used these slides.

I started with an overview of my top 10 buzzwords for 2013 describing a strategy for each of them:

Secure and Compliant - BIDMC has a multi-million dollar security enhancement program with 14 work streams

Hosted in the Cloud - BIDMC operates 3 private clouds to deliver web-based clinical applications to thousands of users

Service Oriented Architecture - BIDMC builds its own clinical systems using service oriented architectures and enterprise service bus approaches

Business Intelligence - 200 million observations on 2 million patients are searchable via innovative self service data mining tools

Social Networking - BIDMC uses social networking ideas in its clinical applications and uses commercial social networking sites extensively for marketing

Green - BIDMC's data centers support a 25%  annual increase in computing power and storage without increasing our power usage

Federated and Distributed - BIDMC's merger and acquisition strategy depends up on data sharing among peers rather than centralizing clinical applications into one common system

Patient Centered - BIDMC's patient and family engagement strategy includes Patientsite, OpenNotes, and new mobile friendly tools

Mobile BYOD - BIDMC applications run on iPhones, Android devices and iPads (with appropriate encryption)

Foundational for Healthcare Reform - BIDMC has embraced global captitated risk, with over 65% of patients in risk contracts in 2013.

I also described the leadership characteristics needed to implement all these concepts in large complex organizations:

Guidance - A consistent vision that everyone can understand and support.

Priority Setting - A sense of urgency that sets clear mandates for what to do and importantly want not to do.

Sponsorship - "Air Cover" when a project runs into difficulty.   Communication with the Board, Senior Leadership, and the general organization as needed.

Resources - A commitment to provide staff, operating budget, and capital to ensure project success.

Dispute resolution - Mediation when stakeholders cannot agree how or when to do a project.

Decision making - Active listening and participation when tough decisions need to be made.

Compassion - Empathy for the people involved in change management challenges.

Support - Trust for the managers overseeing work and respect for the plans they produce that balance stress creation and relief.

Responsiveness - Availability via email, phone,  or in person when issues need to be escalated.

Equanimity - Emotional evenness that is highly predictable no matter what happens day to day

The students were a great, energetic and inquisitive group.   I want to thank Columbia for the opportunity to speak with them.

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Building Unity Farm - Creating the Orchard

In March, I wrote about our planning for the Unity Farm orchard.

Just as with any IT project, we needed to create a charter (aims, success factors), a Gantt chart, project management, and a team structure to successfully "go live" with our orchard.

Our charter is simple - use 1 acre of our 15 acres for fruit and and nut trees in support of self sufficiency and local fruit production.   Success will be clearing the weeds, vines, and shrubby trees that constitute young forest on the disturbed land below our pasture, which was likely cleared 20 years ago as part of the original grading of the land.   This section of forest is our most challenging to manage and is the area responsible for the total body poison ivy experience I had last Summer.

The project plan involved a comprehensive survey and wetland border analysis (done by GLM Engineering Consultants), a review of the land management plan with the town of Sherborn, an orchard planting plan (done by Tree Specialists), a deer fence design (done by River Valley Fencing), a forestry management company for tree removal (Stumpy's), an irrigation company (Bourque Brothers), and a site preparation/excavation company (will be selected by the end of the week).

With all the plans and approvals in place, we began clearing forest on Monday.   As of today, the majority of the 1 acre is cleared of poplar and the thick underbrush that was choking new growth.    There were 5 oaks, which I saved for mushroom farm Shitake production.   This weekend, I'll cut the 3-6" branches into 220 four foot logs in 22 stacks.   I've ordered 60 pounds of sawdust spawn to inoculate the logs the weekend of May 11-12.

Here are pictures of the orchard area before and after the clearing.

Our next step is to  grind stumps, prepare the land by removing rocks/roots, add topsoil, plant the 30 trees, and spread the orchard grass/meadow seed mix which will prevent erosion and support pollinators.    Our bees arrive later this spring.

By mid-May the entire project will be done and the 8 foot deer fence will be up.   Yes, it will take years before our apples, pecans, chestnuts, and blueberries will be in full production, but the sooner we start, the sooner we'll be harvesting!

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The Importance of Giving Your Time

I've written about servant leadership and the special gift of sharing time with others .  (It's hard to believe that my father and I enjoyed that day meandering the mountains of Northern California just 5 years ago)

My wife recently emailed me a New York Times Magazine article entitled "Is Giving the Secret to Getting Ahead?"  and it really resonated with me.

Every day I receive numerous requests from students, colleagues, and community collaborators for meetings, phone calls, and speaking events.

Just as the New York Times article suggests, I do not see these requests for my time as a distraction getting in the way of my job.   I see serving the healthcare IT community and the stakeholders throughout the world as my job.  

It can be fatiguing to serve so many people in so many contexts, but time spent sharing a vision or helping break down a barrier makes a great difference to everyone involved.   The power of ideas communicated with clarity and enthusiasm may have a disproportionately  positive effect when the perfect storm for innovation occurs due to an alignment of people, processes, and possibilities.

I try every day to help and serve those around me, without an expectation that my energy and time will have a specific payback.    

However, enough odd coincidences happen to me that I know my time is having an impact.  Last week I was having breakfast at the Cambridge Hyatt with a few Canadian Healthcare Executives and a person I have never met approached our table and said  "Thank you for writing about Unity Farm and my condolences on the death of your father."

When random strangers are affected by the things you do, the thoughts you think, or the words you write, you know that your time is well spent.

My advice - when a young person ask for mentoring, a colleague asks for career advice, or a community contact asks you to speak to a group of concerned stakeholders, say yes.   Giving your time is your best opportunity to make the world a better place.

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Printing From an iPhone/iPad

I was recently asked how to print directly from an iPhone or iPad.

Surprisingly, it is not sufficient to use a printer connected to an Airport Express or Airport Extreme wireless network.

To print directly from an iPad / iPhone you need an AirPrint compatible printer or another device to act as a print server.

Here's a list of AirPrint compatible printers  

If you want to use an existing printer, it is possible but requires third party products.

A Mac computer can function as a print server for iPhones/iPads if you buy Printopia or HandyPrint 

The Mac must be "on" but may be asleep for them to work.

You can also buy this standalone print server.

I recently AirPrint enabled my mother's household using an HP 1606dn Laser Printer which is AirPrint enabled.    It is very simple to use  and unlike software-based solutions, it is operating system version neutral.

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Building Unity Farm - Forestry Management

Unity Farm has over 12 acres of forest, which I manage using my Stihl 290 Farm Boss chainsaw and my Scandinavian Forest Axes

I've written previously about managing firewood and logs for mushroom farming

Recently, as we've worked with Tree Specialists on a land management plan that includes an expanded orchard, bees, wildflowers, meadow, and wetland, I've  learned more about tree identification.

As a mushroom expert doing toxicology consultation on the 2500 species of mushrooms in North America, I've become quite comfortable with identification keys.  Recently Barbara Keene of Tree Specialists walked the forests of Unity Farm and taught me how to distinguish white/red oak, red/norway maple, black/sweet birch, cedar, poplar, hickory, ash, dogwood, and elm.

What's the technique?

First, look at the branching pattern of limbs and twigs.  

Maples, Ash, Dogwoods, and Horse Chestnut have opposite branching.    Oaks, birches, poplars, hickory, and elm have alternating branch patterns.

Next, look at the bark

Ash has a diamond-like raised bark pattern. Birches have paper-like peeling bark.  Poplar has a distinctive fissured and ridged bark.  Hickory bark forms ridges in a vertical pattern.   Dogwood is "square plated".     Elm bark is rough and coarse, with intersecting ridges.   Cedar is "string-like".

Finally, look at the buds and nuts.

Maples have distinctive large buds in the spring .   Hickories have a distinctive nut (a favorite of Euell Gibbons)

Thus,  once I've found an opposite branching pattern the presence of a raised diamond or square bark pattern is sufficient to distinguish maples, ash, and dogwoods.

For alternating branch patterns, the presence of paper-like, fissured, vertical ridges, or rough intersecting ridges is enough to distinguish oaks, birches, poplars, hickory, and elm.

The texture and silhouette of cedars (and aroma) are unmistakable.

Buds and nuts help confirm the identification.

Armed with this knowledge, I can harvest fallen branches or dying trees for firewood, mushroom cultivation, or projects that require wood on the farm.   Over time, with help, I'll become a competent forest manager.

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The March HIT Standards Committee Meeting

The March HIT Standards Committee focused on streamlining test scripts for certification, an overview of FDA Universal Device Identifier rule making, clinical summary formats for Long Term Care, and the latest updates from ONC.

We began the meeting by reflecting on the recent HIMSS conference, noting that the culture and momentum for EHR and HIE adoption in the US have changed to the point that there is no longer of question achieving our meaningful use attestation goals.

Liz Johnson and Cris Ross provided an overview of the implementation workgroup review of testing scenarios.     Their goal has been to increase the clinical relevance and decrease the burden of testing for certification.   A scenario-based sequence approach enables the reuse of data across multiple tests are part of continuum of functional evaluation.    Part of the work of this group is to ensure the tools provided for testing (9 different tools for Meaningful Use Stage 2) work well and that pre-testing entry of data is allowed, reducing the time of testing procedures substantially.

Next, Terrie Reed presented the FDA's Unique Device Identifiers work.   She discussed the two standards that would be used - GMDN for categories of devices and the use of globally unique identifier for each product (GUDID).   Her analogy to medication vocabulary standards is that GMDN is like RxNorm (a chemical name) and GUDID is like NDC (a specific package size).   She also noted that the regulation will include all medical devices.   The standards committee advised her that the regulation should cover consumer devices used for healthcare as well, so that EHRs and PHRs can be more easily interfaced to consumer devices.

Bill Russell and Larry Garber presented an excellent overview of Long-term Care Coordination standards work, noting that CCDA would benefit from additional templates.

Finally, Judy Murphy and Doug Fridsma presented ONC Updates.

Over the next month, the Standards Committee members will continue their workgroup efforts to select foundational standards for Meaningful Use Stage 3.    I look forward to our next meeting.

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The Reality of SaaS

Recently I was asked if SaaS/Cloud computing is appropriate for small practice EHR hosting.

I responded

"SaaS in general is good.

However, most SaaS is neither private nor secure.

Current regulatory and compliance mandates require that you find a cloud hosting firm which will indemnify you against privacy breeches caused by security issues in the SaaS hosting facility.

Also, SaaS is only as good as the internet connections of the client sites.   We've had a great deal of experience with 'last mile' issues"

To add further detail, Bill Gillis, the CIO of the Beth Israel Deaconess Care Organization (BIDCO) responded

"We built, manage & maintain our own private cloud in a Co-location facility.  Our EHR cloud is served to the practice via public internet over SSL. One challenge we struggle with is ISP availability and service level/stability.  In Metro Boston one would expect a robust internet infrastructure.  We've found heterogeneous public internet capabilities and quality of service.  We've found that getting a good ping response is not truly an indicator of meeting application performance requirements.  Many cloud hosted applications are sensitive to latency, packet loss, fragmentation & jitter.

In the first year of our project deployment we struggled because the ISP connectivity did not appear to be the culprit.  A practice would have 10+ megabit connections with ping returns under 25ms.  Yet the practice would experience application freezing, crashes or very poor/slow response time.  From the public ISP's perspective 'the lights were green' and they would take no further action.  After engaging third party network sniffing firm, we discovered the real culprit impacting performance - network latency.  We were able to take the data from that engagement back to the ISP to illustrate the problems with the packets in transit.

Implementing network sniffing engagement was time consuming and costly.  Doing this for the 100+ practice locations we were supporting is not sustainable.  Luckily we found a company in Boston called Apparent Networks (now called Appneta).  Appneta makes a small, low cost black box application that provides deep and detailed network data back to a secure cloud.  We place a device in a practice that communicates back to a device we keep in our hosted/central site.  The devices continually communicate with each other and log all of the various degrees of network performance up to the cloud.  The best part is we preconfigure the devices and mail them to the practices reporting issues.

 All the practice staff need to do is provide power and plug it into an open Ethernet port.  This saves us from deploying a technician on-site.  Since we first deployed these devices we've been able to get to the root cause of performance issues and resolve them rapidly.  We've been able to identify everything from an ISP charging for a certain level of bandwidth while only providing 1/2 that speed to staff streaming media during high volume hours saturating the local router.  The performance data is stored in the cloud indefinitely.  This give us a longitudinal view of the network/internet connectivity for a specific practice.  Recently we were able to avoid a potential issue by noticing that a practice's connection stability was slowly degrading over the past year.  We were able to work with the ISP to discover they had an issue with a local Central Office/substation.  The reality is most ISP's are not that willing to work with us until we show them the data.  Once we have the smoking gun, they tend to dig deeper and work with us to resolve the problems.  For all the high-tech equipment we've leveraged for our private cloud, this device was the real swiss army knife of the project."

I've described Cloud Computing as "your mess run by someone else".   It can be done successfully, but SaaS is only as good as the privacy protections you purchase or build yourself.   Performance is only as good as your network connection.

I hope this is helpful.

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Building Unity Farm - Managing the Farm in Our Absence

Paul Harvey wonderfully captured the responsibilities of being a farmer.  Just like being a CIO, being a farmer is not a job but a lifestyle.

When I called my wife and daughter in the hours after my father's death last week, we had to figure out how to manage Unity Farm during a situation that required the absence of the entire family.

We created a workplan and contacted a nearby farm to ask for their help.

Here's what we had to document

Alpaca/Llama care
  Hay management in two indoor and two outdoor feeders
  Twice daily grain feedings
  Heated water bucket filling
  Snow clearing in the alpaca paddocks
  Manure management in the barn, paddocks, and composting area

Chickens/Guinea fowl
  Feeder filling (with multi-flock crumbles)
  Providing greens (romaine lettuce)
  Heated waterer filling
  Coop cleaning
  Opening and closing the coop during daylight hours
  Counting all the birds to ensure they return from their free range adventures
  Turning on the inside lights during the day and off at night (guineas will not roost in a dark coop)

Dogs
  Feeding the dogs in the evening
  Heated water bucket filling
  Providing them snacks and toys

Rabbits
  Lettuce feeding
  Hutch cleaning

General
  Ensuring fences are not damaged by falling tree limbs or snow drifts
  Managing the electric fences
  Ensuring protective lighting is working to keep predators away
  Keep barn doors closed
  Keep property safe

We never expected to all be away from the farm at the same time, so creating detailed instructions required significant short term work.

A farm hand from our adjacent farm did a wonderful job and I returned on Sunday night to find Unity Farm in perfect shape, other than one barn light that was knocked down by a falling tree limb.    Kathy stayed with my mother an extra week and returns to the farm on Saturday.     Just as IT professionals plan for redundancy and disaster recovery,  Kathy and I have learned the importance of contingency planning for the farm.    We have been an inseparable team for 33 years.   Keeping all our professional and personal activities in balance is easy when we're together, but nearly impossible when we're apart.

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