tag:blogger.com,1999:blog-26949635791278912962024-03-18T20:57:58.027-07:00themakingofanursemidwifedssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.comBlogger508125tag:blogger.com,1999:blog-2694963579127891296.post-48960179953348253152014-02-15T02:34:00.002-08:002014-02-15T02:34:35.253-08:00Health and Fitness Magazines<div id="article-content" style="text-align: justify;">
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Today, maintaining health and fitness have become more important
than ever before. With illnesses becoming more often, we have to equip
ourselves with everything necessary to maintain health and have a good
quality of life. One of the best ways to jumpstart your way to better
health is through reading health and fitness magazines. These magazines
offer helpful tips, advice and recent discoveries about health that
should come handy. Note that although fitness magazines are aimed mainly
at body- and health-conscious audience, everyone will surely benefit
from all the information they provide. Here are some of the most popular
health and fitness magazines today:</div>
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<b>Muscle & Fitness Magazine</b></div>
<div style="text-align: justify;">
This
magazine was released mainly for bodybuilders. However, if you are
conscious about your health and do workouts, you can use vital
information on this magazine. There is a version of this magazine called
Muscle and Fitness Hers aimed mainly towards health-conscious ladies.
This magazine contains tons of information that can range from
bodybuilding foods, diet programs, weight loss strategies, workout
information, supplements, and other recent discoveries.</div>
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<b>Shape Magazine</b></div>
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Shape
Magazine has been edited to help you get a better understanding of
fitness. It features articles from experts in the fields of nutrition,
exercise, beauty and psychology. Shape is mainly geared towards fitness
enthusiasts who surely will benefit from each and every bit of
information that the magazine contains. It highlights news, step-by-step
guidelines, recipes, and tips in beauty, fashion, style, and everything
in between.</div>
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<b>Men's Fitness Magazine</b></div>
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Men's Fitness is
also a magazine designed for the modern health conscious men. It
contains articles containing important details on maximizing workout,
optimal diet and nutrition necessary for perfect fitness. Each issue is
aimed at showing you how to properly workout your specific body parts,
look better, unleash your sexual drive, and essentially put adventure
back into your life.</div>
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<b>Subscribing Health and fitness magazines</b>
cover everything a health and body-conscious person needs to know. If
you are aware of the importance of maintaining tiptop health, and are
actually doing something about it, a subscription to these types of
magazines will provide you great discounts than buying them at the
newsstand. Health and fitness magazines are usually offered in an
attractive price package through websites.</div>
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Consider subscribing to
a health and fitness magazine as an investment for your health and
yourself. There is nothing more important than valuing health. Today, it
may seem like an added financial burden but the long-term benefits that
reading about health can give are far worth it. Besides, you can get
subscriptions at rock bottom, discounted prices. However, be careful
with the website you will subscribe to. Trust only the most reliable
website that has a good reputation online.</div>
</div>
dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-47101557110632988342014-02-13T03:00:00.000-08:002014-02-15T02:37:00.210-08:00Building Unity Farm - Managing the Woodland, Manure, and Bees in Winter<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiB1hN1TwLrO5_iHQSnv6ACjXtrZ3A9cQCpKvh0Xwr0dEfoYLA1ngI3eYYGOc2uEKbsMQKQwnLIVRCzveMEGguZ80jKdF_64zckGbVcdrgi__m2986uMTVV_z1qKNF2XkPnnKTmx-8HUy8/s1600/photo.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiB1hN1TwLrO5_iHQSnv6ACjXtrZ3A9cQCpKvh0Xwr0dEfoYLA1ngI3eYYGOc2uEKbsMQKQwnLIVRCzveMEGguZ80jKdF_64zckGbVcdrgi__m2986uMTVV_z1qKNF2XkPnnKTmx-8HUy8/s1600/photo.JPG" height="200" width="150" /></a>I've written about our winter preparations and keeping the animals healthy in the 6 months of sub-freezing weather we have in New England. It's been a particularly cold winter in Massachusetts. It's currently 2 degrees F and we're expecting another foot of snow.<br /><br />As the snow gets deeper, the icicles get longer, and all unheated water becomes a solid chunk of ice, how do we manage our weekly work routine on the farm?<br /><br />Our 15 acres of woodland require constant maintenance - bucking fallen trees, removing broken branches, repairing trails/bridges, splitting wood, and making chip piles.<br /><br />The new Terex PT30 compact track loader makes this job infinitely easier since I previously used a 6 cubic foot wheelbarrow and heavy duty cart to haul logs, branches, and chips. I've removed trees, brush and rocks along our 1 mile of trails to accommodate the 48" width and 10" ground clearance of the Terex, so I now can reach any portion of the 15 acres with the Terex. Last week, after a foot of snow, I used the Terex to clear working paths through the barnyard, manure management bins, and wood processing area. Every week I split about 1/2 cord of wood by hand, which is challenging to do with a few feet of snow on the ground. My solution is to clear trails with the Terex then use a snow sled to haul wood from the splitting area to the storage area and from the storage area to the fireplaces. "Sledding" on the farm has definitely improved our winter work efficiency. The carts and wheelbarrow are getting a rest until the snow melts.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdtftDxUIEM5riKKXwy8CvZ9o3Nz1RUvNdW2QJ2IdLF2mODlPzLyBSsKk3Zie5tatjbqMt1Bc1oxdranVYY2x9QVgaKc1I-x5p3I8MxGHFOqIDoLopg6rqM7p_tlQI0wMGnRkCzXm7B9Ht/s1600/photo+1.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdtftDxUIEM5riKKXwy8CvZ9o3Nz1RUvNdW2QJ2IdLF2mODlPzLyBSsKk3Zie5tatjbqMt1Bc1oxdranVYY2x9QVgaKc1I-x5p3I8MxGHFOqIDoLopg6rqM7p_tlQI0wMGnRkCzXm7B9Ht/s1600/photo+1.JPG" height="320" width="240" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjltfDE9iLFKp38qJRqVt0deoz_-BdlUhprSVH1mYN7rhNyLoPpt7KaHcxIjjkxLrDNXCqBzFOMx-QOQS8BZ9VBuPejQcsYkRA8-ic33IJqQ4iWNUB47nptkJ_Ewin2X2fcaUhhc3QMZEGa/s1600/photo+2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjltfDE9iLFKp38qJRqVt0deoz_-BdlUhprSVH1mYN7rhNyLoPpt7KaHcxIjjkxLrDNXCqBzFOMx-QOQS8BZ9VBuPejQcsYkRA8-ic33IJqQ4iWNUB47nptkJ_Ewin2X2fcaUhhc3QMZEGa/s1600/photo+2.JPG" height="320" width="240" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMzecpKmzXEdrUeUTcFYDtV4mbvfyXHIfGOeusuyM_19ZHyOBQ-PdrCRoEDickdUPWmbaQ3ECgpL47ikUEQ_RiiqekyPHiEPUoZl1ZnVHMlxRIkrHOb1igvhqU1yc2FroZyoNDlDcZyzO0/s1600/photo+3.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMzecpKmzXEdrUeUTcFYDtV4mbvfyXHIfGOeusuyM_19ZHyOBQ-PdrCRoEDickdUPWmbaQ3ECgpL47ikUEQ_RiiqekyPHiEPUoZl1ZnVHMlxRIkrHOb1igvhqU1yc2FroZyoNDlDcZyzO0/s1600/photo+3.JPG" height="320" width="240" /></a></div><br /><br />Manure management (10,000 pounds per year) is challenging at 2 degrees F in two feet of snow. Although the manure is biologically warm, the sub-freezing weather yields a frozen blend of manure, hay and snow. I use an ice chipper to break up the manure in the barn stalls and then move it to a sled dedicated to manure hauling. As you'll see in the pictures below, we have our own bobsled tracks for manure management during the winter. I doubt manure bobsled will ever be an Olympic event.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhc0iY7vvwpkF7U2JiGKcAo1gIBzEq8I42YikDqDdQ1JB07aNNVmat1RjKMKV22hAMN4BaBiYLcOopNA2C78zTz9oDtXSIkcamNJNZOVb45CBvJFYVZiBvk9YO-Jgkh086Uvc5h72nbCAUH/s1600/photo+4.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhc0iY7vvwpkF7U2JiGKcAo1gIBzEq8I42YikDqDdQ1JB07aNNVmat1RjKMKV22hAMN4BaBiYLcOopNA2C78zTz9oDtXSIkcamNJNZOVb45CBvJFYVZiBvk9YO-Jgkh086Uvc5h72nbCAUH/s1600/photo+4.JPG" height="320" width="240" /></a></div><br />We have over 100,000 bees at Unity Farm, spread in 8 hives, each with 2 deep hive bodies and 10 frames. We entered the winter with 7 strong hives, and 1 weak hive. Although we stopped harvesting honey in August and left plenty of food stores for the bees in winter, we supplement the hives with bee tea (in a 1 gallon tank that fits in the hive) and fondant. Here are the recipes<br /><br />Bee Tea<br />10 cups can sugar<br />6 cups hot water<br />fresh or dried chamomile and/or time<br />1 teaspoon sea salt<br /><br />Combine sugar and salt. Add hot water and stir thoroughly. Boil 2 cups of water and add herbs. Steep for 10 minutes. Strain and mix into sugar water solution. Cool and feed to bees.<br /><br />Fondant<br />5 pounds sugar<br />1 pint light Karo syrup<br />1 1/3 cups water<br /><br />Heat in a saucepan to 242°F while stirring constantly – this mix will be boiling for about 5 to 8 minutes before it reaches 242°F . Take if off the heat and let it sit for about 10 minutes to start the cooling process. You then must start stirring until it completely cools. This will take about 20 minutes. It will get whitish in color and thicken up. Once this happens, then you can pour onto paper plats. Don’t wait too long or you will not be able to pour it and get it to the thickness that you need to put in the hives.<br />(1/4"). When ready to feed, remove paper, break in half and place both halves on the top of hive frames.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0tA6_S4mZYZ9UAbo37oXPKT1nUSD3kbxAel_Xz8zfMpT9Zy6q53KUdYF9W57QYxM_DeALM7cjKTHSgPCt50hikQ5JJIZGvQ8_N4WxrpzU3BzsofM_U4njQIWcNl65wH4R_EX60rW5564p/s1600/photo+5.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0tA6_S4mZYZ9UAbo37oXPKT1nUSD3kbxAel_Xz8zfMpT9Zy6q53KUdYF9W57QYxM_DeALM7cjKTHSgPCt50hikQ5JJIZGvQ8_N4WxrpzU3BzsofM_U4njQIWcNl65wH4R_EX60rW5564p/s1600/photo+5.JPG" height="320" width="240" /></a></div><br />Finally, we think of Unity Farm as part of the Massachusetts agricultural community and immediately volunteered to help in <a href="http://www.boston.com/news/local/massachusetts/2014/02/11/abused-animals-seized-from-ludlow-property/XgsNpHrh5z9kAmqraVOjGK/story.html">this rescue situation</a>. I'll post additional details as we get more involved.<br /><br /><br />dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com1tag:blogger.com,1999:blog-2694963579127891296.post-76183133056968056872014-02-12T03:00:00.000-08:002014-02-15T02:37:00.219-08:00Time for a New Optimism<div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><span style="text-align: -webkit-auto;">Readers of my blog know that over the past year, I've written several posts warning about the burden of 2014 certification, the timing overlap of numerous federal programs including ICD10, and my observations that IT professionals/providers are at the breaking point.</span></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">However, I have reasons to be optimistic and it's not just the approach of Spring.</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">1. There is a new national coordinator who is a great listener</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">I have every expectation that Karen DeSalvo will gather input from stakeholders and adjust the trajectory of national HIT policy within the limits of regulatory process constraints. She understands the impact of the current federal programs and the challenges providers face getting through each day. She knows there is a balance between appropriate regulation and over regulation. She knows that cultural change, even driven with stimulus and urgency, requires incremental progress over time. We've already seen a few timeline extensions (an extra year of Stage 2, extra time for hospitals and EPs to attest to 2013 reporting periods) and I expect more to come.</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">2. There is an opportunity to rethink certification</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">With CCHIT's closure, delays in 2014 certified product availability, and significant stakeholder discussion about the certification process, all are aware of the need to revise certification. I envision a day when ONC and its Federal Advisory Committees formulate policy goals for certification (i.e. quality improvement depends upon measurement), but then those actually doing the front line work (vendors, providers, payers, patients) develop practical certification scripts that ensure software supports the policy goal.</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">3. The <a href="http://www.modernhealthcare.com/article/20140206/NEWS/302069958/proposed-sgr-overhaul-would-affect-ehr-incentive-program">Sustainable Growth Rate (SGR) bills</a> consolidate PQRS, Meaningful Use and the Value-Based Payment Modifier into a single program, eliminating penalties.</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">Meaningful Use has been a remarkable program, achieving rapid adoption of EHRs in hospitals/professional offices and fundamentally changing the cultural expectation of automation in healthcare. The SGR bills transition the Meaningful Use construct from a special program to an operational part of value-based purchasing. Making IT performance part of operational activities related to reimbursement will even out the pace of work.</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">4. Meaningful Use might become a stretch goal instead of a floor</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">If Meaningful Use moves into a “Merit-based Incentive Payment System”, eliminating penalties, the program becomes a way for early adopters and innovators to be recognized for their efforts. It was very appropriate that Meaningful Use Stage 1 and 2 set a floor and became a tide that floated all boats. Going forward, it will be very challenging, if not impossible in a resource constrained world, to ensure every healthcare organization performs on the bleeding edge of innovation. Merit based incentives enable organizations to evolve at their own pace.</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">5. Meaningful Use is not the solution to every problem and there are signs that other approaches may be used</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">It's been an honor to work on Meaningful Use, but by 2016, we need to declare victory to avoid having an ongoing special program through which every interested party inside and outside government sees an opportunity to accelerate their own priorities, creating meaningful use fatigue. Pilots, grant programs, datapaloozas, pay for performance incentives, and competitions all enable us to move forward the technology agenda with a better balance of benefit/burden than an everlasting Meaningful Use program. </div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">Finally, as ONC and its committees focus more on interoperability that empowers innovation instead of prescriptive functionality (the EHR must do X, Y, Z), we need a roadmap. I'm very optimistic that the schedule below (which I sense is developing organically among vendors, SDOs, and policy experts) will lead to much more data liquidity, care coordination and patient empowerment in a timeframe that enables us to overcome cultural resistance and policy barriers:</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">1. CCD - unified CCR and CDA, first time vendors began exporting a summary, ad hoc device interoperability (2011)</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">2. CCDA - much more constrained, first time vendors began importing a summary, Continua Alliance IEEE 11073 products emerge, FDA guidance issued (2014)</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">3. FHIR/REST - much easier to implement, will result in a substantial increase in modular products connecting to monolithic EHRs, Continua Alliance IEEE standards recommended, no device data transport standards specified (2017)</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">4. APIs - will expand the number of shared data elements from hundreds to thousands and enable read/write workflows, Continue Alliance IEEE standards required, device data transport options recommended (2020)</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">5. Detailed Clinical Models (ie. <a href="http://informatics.mayo.edu/CIMI/index.php/Main_Page">Clinical Information Modeling Initiative</a>) which will begin to standardize the schemas underlying EHRs and then interoperability can happen via APIs linked to standard schemas, ensuring data integrity from point of origin to point of use, device data transport standards required (2023)</div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;"><br /></div><div style="font-family: Helvetica; orphans: 2; text-align: -webkit-auto; widows: 2;">In times of struggle, there is opportunity. 2014 is the most stressful time in healthcare IT in our generation. From that struggle will come a reasonable path forward we can all support.</div>dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com1tag:blogger.com,1999:blog-2694963579127891296.post-65889848635105573702014-02-06T03:00:00.000-08:002014-02-15T02:37:00.226-08:00Building Unity Farm - 'B' School BeginsAs I mentioned last week, my wife and I have enrolled in an evening Bee school to formalize the beekeeping knowledge that to date we've picked up from books and our early experiences with 8 hives at Unity Farm.<br /><br />It's been a hard winter in Massachusetts. Over the past 24 hours, Unity Farm has had over a foot of wet, heavy snow. We're waiting for a warm day to open the hives and check on the bees. Although we've provided supplemental food and kept the hives dry, there is a high overwinter bee mortality in New England, with about 80% of colonies dying. <br /><br />The bee school will provide us with the best practices and a schedule to maximize the health of our bees.<br /><br />In many ways, beekeeping is like IT - it requires infrastructure and ongoing maintenance. Just as with tractors, asking 12 beekeepers for advice results in 13 different recommendations. Based on all our reading, discussion, and training thus far, we're planning to standardize our hives and tools this Spring as follows:<br /><br />Each hive<br /> 2 Deep Hive Bodies<br /> 2 Medium Hive Bodies as "Supers"<br /> 20 Deep Frames/Foundation, Divided<br /> 20 Medium Frames/Foundation, Divided<br /> Telescoping cover<br /> Inner cover<br /> Screened bottom board<br /> Entrance reducer<br /> Hive stand<br /> Hive top feeder<br /> Queen excluder<br /> Escape Board Screen<br /><br />Tools<br /> Smoker/Fuel<br /> Hive Tool<br /> Bee Brush<br /> Frame Grip<br /> Capping scratcher<br /> 9 frame spacer tool<br /> Fumagillin<br /><br />Clothing<br /> Bee Suit<br /> Bee Veil/Helmet<br /> Gloves<br /><br /><br />We also may need to add new bees to our hives and there may be a shortage this year. Many bee colonies are overwintered in Georgia. The "polar vortex" brought freezing temperatures to the most dense apiary areas. We've ordered several 3 pound "packages" with queens to ensure we're prepared.<br /><br />We're very excited to take on the additional responsibility of supporting our bees, armed with new knowledge, just as we've taken responsibility for the 100 animals of Unity Farm, keeping them happy and healthy throughout the year.<br /><div><br /></div>dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-72978420787873237842014-02-05T03:00:00.000-08:002014-02-15T02:37:00.232-08:00Standards for Patient Generated Healthcare DataAt last week's Meaningful Use Workgroup meeting, Leslie Kelly Hall and I reviewed the HIT Standards Committee recommendations for patient generated healthcare data from online applications and devices.<br /><br />We offered guiding principles for Meaningful Use Stage 3 in general. Meaningful Use should avoid "certification only" items since requiring engineering in products to support untested workflows with immature standards is unlikely to accelerate progress. We should only apply standards/certification to those processes where they are needed and useful.<br /><br />For patient generated data sent from interfaced applications, CCDA is recommended as a container for types of templates that are well understood (e.g. problems, meds, allergies). CCDA over existing (Direct, Exchange) and other modes of transport are reasonable ways to get data in and out of EHRs, PHRs, and patient facing applications.<br /><br />CCDA should not be required as the architecture that integrated applications must use. The outcome goal is for the entire care team (patient/families/providers) to be able to contribute to a shared medical record and that can be achieved without CCDA in a fully integrated application. We need to allow for innovation and flexibility in this area and not unduly constrain options for individuals to connect with their care teams in the ways they prefer. <br /><br />For patient device generated data, we need to support innovation, as the marketplace is still rapidly evolving.<br /><br />Continua implementation guides (and their underlying IEEE 11073 standards) are directionally appropriate, but ONC needs to align certification with FDA guidance and other regulatory or sub-regulatory policy without constraining the marketplace.<br /><br />Due to the immaturity of the market, we need to be flexible regarding incorporation of device data and other remote data sources. Thus, we do not believe a specific standard should be mandated at this time, just an attestation requirement that some approach has been used successfully.<br /><br />We are fully supportive of efforts to integrate patient generated healthcare data from applications and devices into provider workflows. By using the CCDA and encouraging market-based innovative device integration, we believe burden and benefit can be balanced.<br /><br /><br />dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com1tag:blogger.com,1999:blog-2694963579127891296.post-47036673679477733252014-02-05T02:33:00.000-08:002014-02-15T02:34:15.096-08:00Health and Fitness - How to Start Getting Yourself Back in Shape<div id="article-content" style="text-align: justify;">
<div style="text-align: justify;">
A person's health does not refer to his or her body only, but to
every aspect of that person's well being. Health includes the physical
aspect of an individual as well as his or her mental and emotional well
being, too. The medical community strives to protect people from the
damaging effects of both physical and mental illnesses, which is why the
term "health" encompasses so much more than the physical. So, in order
to live a fulfilling and rich life, a person must pay close attention to
his or her overall health, not just individual aspects of it. This is
why there are so many different health and fitness programs available to
people today.</div>
<div style="text-align: justify;">
In order to maintain a healthy body and mind, you
should definitely stick to a good fitness plan. This may mean joining
the local fitness center, engaging in daily physical activity, or buying
some home fitness equipment. Depending on your lifestyle, available
time, and where you live will determine which type of health and fitness
plan is best for you. Once you have decided on the right fitness plan
or regimen, be sure to stick to it. As long as you adhere to your
fitness program you will definitely begin to look, feel, and work
better. Being physically fit will affect every aspect of your life in a
very positive way.</div>
<div style="text-align: justify;">
When considering a new fitness program, it is
important that you take into consideration your gender, age, eating
habits, and level of current activity. It is important that you enter
into a new fitness regimen carefully and always after you have discussed
the plan with your doctor. Many times, people become very enthusiastic
about the prospect of improving their overall health and fitness which
makes them make poor choices and over exert themselves. Over exertion
will do more harm than good, so even if your goal is to lose fifty
pounds (as long as it is a healthy amount of weight to lose based on
your height and body type), you should work consistently at it rather
than obsessively.</div>
</div>
dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com2tag:blogger.com,1999:blog-2694963579127891296.post-59512258528175218292014-02-04T03:00:00.000-08:002014-02-15T02:37:00.237-08:00The Meaningful Use Workgroup RecommendationsToday at the HIT Policy Committee meeting, the <a href="http://www.healthit.gov/facas/calendar/2014/02/04/hit-policy-committee">Meaningful Use Workgroup</a> will present its recommendations as part of the process leading to a final rule in 2015:<br /><br />Feb 2014: Draft stage 3 recommendations reviewed with HITPC<br />March 2014: HITPC approval of stage 3 recommendations<br />Fall 2014: NPRM for stage 3<br />1st half 2015: Final Rule for stage 3<br />Effective: 2017<br /><br />I presume the regulation writing will follow previous approaches with ONC writing the certification rule and CMS writing the attestation rule.<br /><br /><a href="http://geekdoctor.blogspot.com/2014/01/advice-to-new-national-coordinator.html">As I've written about recently</a>, I think it is important to evaluate Meaningful Use Stage 3 from several perspectives including workflow impact, standards readiness, and the tension that such regulations create by prescribing functionality in products, reducing the ability of organizations and vendors to set their own priorities.<br /><br />The certification criteria noted in the Meaningful Use Workgroup slides are enumerated below and I've added my own discussion questions. It’s important to assess not only the merits of each of the criteria, but their cumulative effect. Each hospital and physician office will have to trade-off meeting these requirements instead of doing something else, because few if any providers have the bandwidth to take on more.<br /><br />In addition to the detailed discussion points below, I suggest that each of the criteria meet a three-part test before being considered for Meaningful Use Stage 3: 1) is there evidence that the specific technology function, if used, would substantially improve the quality, safety, efficiency, or affordability of care? 2) do we believe that the market will not adequately address the requirement on its own 3) will there be sufficient, uniformly available state-level and industry infrastructure in place to make the required technology achievable?.<br /><div><br /></div>When I write about such topics, I have to select my words very carefully. Throughout much of my life, I've been viewed as an edgy innovator. At this period in my career, some view me as the status quo, resistant to change. When I propose discussion questions below, I am not taking a position for or against a policy goal. I'm trying to weigh the cost/benefit of regulation at a time when many stakeholders in healthcare are resource constrained, time bankrupt, and struggling to comply with existing regulations.<br /><br />I look forward to the open debate of these issues<br /><br />1. Clinical Decision Support (CDS)<br />Ability to track CDS interventions and user responses<br />Perform age-appropriate maximum daily-dose weight based calculation<br />Consume external CDS rules<br /><br />Discussion questions:<br />a. Will tracking every intervention and user response, a technically challenging activity, substantially impact healthcare quality/safety, research, or efficiency?<br />b. Are standards sufficiently well described/mature to author and exchange externally authored rules? <br />c. Must we require that all rules be transmitted or might we allow options such as decision support services in which rules reside in external modules and only questions/answers are exchanged?<br /><br />2. Advance Directives<br />CEHRT has the functionality to store the document in the record and/or include more information about the document (e.g., link to document or instructions regarding where to find the document or where to find more information about it).<br /><br />Discussion questions:<br />a. Given variations in state regulations for advance directives, will we require structured data standards or accept free text/pointers to free text?<br />b. Can we eliminate the "OR" since such criteria become an "AND" for developers<br /><br />3. EMAR<br />CEHRT provides the ability to generate and report on discrepancies between what was ordered and what/when/how the medication was actually administered to use for quality improvement<br /><br />Discussion questions:<br />a. Is tracking every variation/override, a technically challenging activity, a high priority for healthcare quality departments?<br />b. Do discrepancies commonly occur and if so, are these discrepancies clinically relevant?<br /><br />4. Imaging<br />For both EPs (menu) and EHs (core) imaging results should be included in the EHR. Access to the images themselves should be available through the EHR (e.g., via a link).<br /><br />Discussion questions:<br />a. To clarify, does this imply a certification criteria to receive electronic radiology results, analogous to electronic lab results?<br />b. If so, are the standards for receiving radiology results (including vocabularies for naming radiology tests/procedures) sufficiently mature to support such functionality? <br /><br />5. Clinical Documentation<br />Help the reader understand the origin of any copied text and identify relevant changes made to the original text. Example method: provide functionality analogous to “track changes” in Microsoft Word™ to make the original source of copied text clear and any subsequent changes made<br /><br />Discussion questions:<br />a. Today, many organizations address copy/paste with policy. Must we enforce policy with technology?<br />b. Given that many applications are web-based and not a "thick client" such as Microsoft Word, there may be significant technical challenges in distinguishing between typing and pasting. Does the technology exist to support this requirement?<br /><br />6. Test Results Tracking<br />Display abnormal tests<br />Date complete<br />Notify when available or not completed<br />Record date and time results reviewed and by whom<br />Match results with the order to accurately result each order or detect when not been completed<br /><br />Discussion questions:<br />a. Does this imply implementation of closed loop ordering i.e. require electronic ordering of all tests and not use of an ordering portal, faxing, or order sheets?<br />b. Who should be notified via what escalation method when a test is not reviewed or completed?<br /><br />7. Device documentation<br />EPs and EHs should record the FDA Unique Device Identifier (UDI) when patients have devices implanted for each newly implanted device<br /><br />Discussion questions:<br />a. What is the current timeline for UDI implementation in device products?<br />b. What will be done with this information once in the EHR i.e. recall workflow?<br /><br />8. e-Prescribing<br />Access medication fill information from pharmacy benefit manger (PBM)<br />Access Prescription drug monitoring program (PDMP) data in a streamlined way (e.g., sign-in to PDMP system)<br /><br />Discussion questions:<br />a. What is the current state of fill status information standards and their implementation in PBMs/e-prescribing networks?<br />b. Which states have a PDMP system and the capacity to support single sign on/patient context sharing?<br />c. Are standards available for PDMP integration?<br /><br />9. Demographics<br />CEHRT provides the ability to capture<br />Patient preferred method of communication<br />occupation and industry codes<br />Sexual orientation, gender identity (optional fields)<br />Disability status<br />Differentiate between patient reported & medically determined<br />Communication preferences will be applied to the clinical summary, reminders, and patient education objectives<br />Providers should have the ability to select options that are technically feasible for them, these could include: Email, text, patient portal, telephone, regular mail<br /><br />Discussion questions:<br />a. Do we have appropriate vocabularies for capturing these elements as structured data?<br />b. Given current workflows and personnel, do we believe that we can achieve sufficient accuracy in the recording of these elements to support the expected uses of the data?<br /><br />10. Record amendment<br />Provide patients with an easy way to request an amendment to their record online (e.g., offer corrections, additions, or updates to the record)<br /><br />Discussion questions:<br />a. How does this align with current workflow and practice?<br />b. What standards are required to support this function i.e. structured approaches to requesting change versus free text i.e. an email request?<br /><br />11. Patient Generated Healthcare Data<br />Menu: Eligible Professionals and Eligible Hospitals receive provider-requested, electronically submitted patient-generated health information through either:<br />structured or semi-structured questionnaires (e.g., screening questionnaires, medication adherence surveys, intake forms, risk assessment, functional status)<br />or secure messaging<br /><br />Discussion questions:<br />a. As above, we have to be careful when we use the word "OR" since this implies "AND" for developers, meaning that all possible variations of functionality must be implemented. What is the minimum functionality required?<br />b. Are there standards that constrain the kinds of data submitted i.e. CCDA templates?<br /><br />12. Patient Summaries<br />CEHRT allows provider organizations to configure the summary reports to provide relevant, actionable information related to a visit.<br /><br />Discussion questions:<br />a. How would such rules be authored and what standards would be used to represent knowledge?<br />b. What is the definition of relevant and actionable?<br /><br />13. Multi-language support<br />EHRs are capable of providing patient-specific non-English educational materials based on patient preference. At least one patient receives non-English educational material according to the patient’s language preference<br /><br />Discussion questions:<br />a. Is only one non-English language required as a minimum and not a representative sample based on local populations? <br />b. Are standards to support multi-lingual retrieval implemented by educational material providers?<br /><br />14. Transitions of Care<br />EPs/EHs/CAHs provide a summary of care record during transitions of care<br />Types of transitions:<br />Transfers of care from one site of care to another (e.g.. Hospital to: PCP, hospital, SNF, HHA, home, etc)<br />Consult (referral) request (e.g., PCP to Specialist; PCP, SNF to ED) [pertains to EPs only]<br />Consult result note (e.g. consult note, ER note)<br />Summary of care may (at the discretion of the provider organization) include, as relevant:<br />A narrative (synopsis , expectations , results of a consult) [required for all transitions]<br />Overarching patient goals and/or problem-specific goals<br />Patient instructions (interventions for care )<br />Information about known care team members<br /><br />a. Are standards available to support these data elements such as patient goals or problem-specific goals?<br />b. Are there closed loop workflows required i.e. tracking of completed referrals?<br /><br />15. Notifications<br />Eligible Hospitals and CAHs send electronic notifications of significant healthcare events in a timely manner to known members of the patient’s care team (e.g., the primary care provider, referring provider, or care coordinator) with the patient’s consent if required<br />Significant events include:<br />Arrival at an Emergency Department (ED)<br />Admission to a hospital<br />Discharge from an ED or hospital<br />Death<br /><br />Discussion questions:<br />a. Do we have a sufficient vocabulary (NPI, direct address etc.) to identify members of the care team and the means to notify them electronically?<br />b. Are standards sufficiently mature to support each of these communications as structured data?<br /><br />16. Immunizations<br />CEHRT functionality provides ability to receive and present a standard set of structured, externally-generated immunization history and capture the act and date of review within the EP/EH practice<br /><br />Discussion questions:<br />a. Are standards sufficiently mature to support query/response of this data?<br />b. Do public health departments plan to support this functionality?<br /><br />17. Case Reporting<br />CEHRT is capable of using external knowledge (i.e., CDC/CSTE Reportable Conditions Knowledge Management System) to prompt an end-user when criteria are met for case reporting. When case reporting criteria are met, CEHRT is capable of recording and maintaining an audit for the date and time of prompt. <br /><br />CEHRT is capable of using external knowledge to collect standardized case reports (e.g., structured data capture) and preparing a standardized case report (e.g., consolidated CDA) that may be submitted to the state/local jurisdiction and the data/time of submission is available for audit.<br /><br />a. Is the CCDA the appropriate standard to support case reporting?<br />b. Do state/local jurisdictions plan on implementing such workflows?<br />c. Do the appropriate standards and rules for defining reportable conditions exist?<br /><br />18. Registry Reporting<br />Reuse CEHRT data to electronically submit standardized (i.e., data elements, structure and transport mechanisms) reports to one registry<br />Reporting should use one of the following mechanisms:<br />Upload information from EHR to registry using standard c-CDA<br />Leverage national or local networks using federated query technologies<br /><br />Discussion questions:<br />a. Is the CCDA the appropriate standard to support registry reporting?<br />b. As with other "OR" criteria, will EHR vendors have to implement upload AND federated query approaches?<br /><br /><br />Once we answer these questions, we can weigh the impact on clinician workflow, the burden on development resources, and the balance of federal directives versus competing local organizational priorities.<br /><br />Let the discussion begin! dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com1tag:blogger.com,1999:blog-2694963579127891296.post-1515770332382569022014-02-01T02:33:00.000-08:002014-02-15T02:33:31.965-08:00Why Health and Fitness Plus Network Marketing Make a Great Home Business<div id="article-content" style="text-align: justify;">
<div style="text-align: justify;">
When you decide to choose a network marketing company, there are
so many things to consider. You have to think about the company's
compensation plan, learn about their terms of service, etc. However, the
most important choice comes down to the product. If you don't choose
the right product or service, you may never get your business off of the
ground.</div>
<div style="text-align: justify;">
There are some network marketing companies out there with
products or services that are simply too difficult to sell. Those who
do have success with them probably have tremendous sales skills, signed
up their family and friends to join them, or spent years building
themselves up to a high level. It is critical to choose a product that
you resonate with. If you can't believe in it or let alone use it on a
regular basis, what makes you think you can convince others to do so?</div>
<div style="text-align: justify;">
This
is why the health and fitness niche is a winner. I call it an evergreen
niche because almost everyone will at some point in their lives want to
improve their health. Improving one's health could be losing weight,
getting into shape, or maintaining their current health. It is a niche
that will never run dry!</div>
<div style="text-align: justify;">
The problem is that many of the products
that are in the network marketing industry are not ones that promote the
proper way to get healthy. They may sell at first because of the "magic
bullet" effect of society seeking an easy fix in a pill or shake. Yet,
when there are little results to show for it, the sales may run dry. You
have to find products that you feel comfortable using, are legitimate,
and truly bring results.</div>
<div style="text-align: justify;">
The great thing about the health and
fitness niche is that you don't have to be a fitness professional to get
started. You just need the desire to utilize the products and become a
living testimonial to how they help you stay in the best shape of your
life. Doing so makes selling as well as recruiting so much easier.</div>
<div style="text-align: justify;">
With
that being said, choose your company wisely! Consider the health and
fitness niche as there are some really excellent products that would
make for a great homebased business.</div>
</div>
<div style="text-align: justify;">
By the way...would you like to learn more about the company I chose that is in the health and fitness industry?</div>
dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-7898030381936030602014-01-31T02:32:00.000-08:002014-02-15T02:33:03.780-08:00Heartburn and Acid Reflux - Health and Fitness Discussion<div id="article-content" style="text-align: justify;">
<div style="text-align: justify;">
It seems there sure is a lot on television about acid reflux and
heartburn these days, and you can barely watch an hour or two of TV
without seeing at least one commercial from a pharmaceutical company
recommending some great new drug, offered by prescription only, with
some fancy name with lots of Z'z, Y's, or X's in it. They promise to
help against chest pains, burping, bloating, gas, ulcers, and fix any of
the symptoms, nausea, causes, and restore you back to a happy you.</div>
<div style="text-align: justify;">
Well,
there is an obvious reason why these Big Pharma companies advertise on
TV, they know these drugs are amongst their biggest sellers out there,
providing 100s of millions of dollars each year to their profit. And
they know they need you to go into your doctor and ask for them by name,
if they are to get you hooked on buying them. Many doctors realize that
when a customer comes in and requests a drug, they better prescribe it
or their client is likely to find another doctor. So they do, because
it's a catch-22.</div>
<div style="text-align: justify;">
"God Bless Advertising" you say, indeed, I agree,
and it is rather unfortunate, as one could easily modify their diets,
for instance the GERD Diet to stop the causes, rather than seek medicine
or treatment to alleviate them from such symptoms. In fact, if you were
to do just a little bit of personal research online, you'd find there
are all sorts of articles concerning heartburn and acid reflux, and
simple things you can do to make things easier on yourself if you suffer
from such things.</div>
<div style="text-align: justify;">
Of course, if you are like most people, you
assume that these TV advertisements and drugs are the answer, and that's
fine, but I'd just hope you'd consider alternatives first. Please
consider all this, and think about it.</div>
</div>
dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com1tag:blogger.com,1999:blog-2694963579127891296.post-14408368172429026472014-01-30T03:00:00.000-08:002014-02-15T02:37:00.244-08:00Building Unity Farm - Automation Arrives<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsQ6N78VYDkbAHUtVfusTx0-mLhmM4Tf5zN3-dmWvWvTPufQ8DiEU8M8SkNeLwmbh-4Agdiu0623wmQECxjeiSH-QLYxN8T0eUP4kpVmy41_2jvhCshIS87L_B0F9v1PboZXdWArDccfGQ/s1600/hill.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsQ6N78VYDkbAHUtVfusTx0-mLhmM4Tf5zN3-dmWvWvTPufQ8DiEU8M8SkNeLwmbh-4Agdiu0623wmQECxjeiSH-QLYxN8T0eUP4kpVmy41_2jvhCshIS87L_B0F9v1PboZXdWArDccfGQ/s1600/hill.JPG" height="132" width="200" /></a>Over the past few months, I've asked a dozen farmers what automation is best for Unity Farm's 15 acres of woodland management, manure movement, trail maintenance, food storage, and orchard harvesting. I received thirteen different answers ranging from:<br /><br />Buy John Deere, Kubota is underpowered<br /><br />Buy Kubota, John Deere is mostly outsourced<br /><br />Buy from your closest dealer, service really matters<br /><br />Don't worry about the dealer, do the service yourself<br /><br />Buy Agricultural tires, they're absolutely necessary<br /><br />Buy Industrial tires, since Agricultural tires will wreck your property<br /><br />Buy a skidsteer/compact track loader for work in mud/snow and on hills. A tractor is for pulling not pushing<br /><br />Never buy a skidsteer/compact track loader, they lack flexibility.<br /><br />What did we buy and why?<br /><br />I know that at least 11 farmers will disagree with me, but we bought a <a href="http://www.terex.com/construction/en/products/new-equipment/compact-track-skid-steerloaders/compact-track-loaders/pt30/index.htm">Terex PT30 Compact Track Loader</a>, pictured above in our orchard. It weighs 3000 pounds, lifts 950 pounds, yet only has 3 PSI pressure on the ground, leaving the trails and turf untouched. The machine is the evolution of the ASV RC30 and has an advanced track system that does not slip in mud or snow. <br /><br />To make the decision, I test drove several devices. With the PT30, I was able to move 12 cubic feet of mulch, haul 400 pounds of logs up a 15 degree slope, clear the orchard road of snow, move 500 pounds of rocks, and execute numerous zero turning radius redirections on snow in less than 45 minutes.<br /><br />Unity Farm is a "compact farm" with one mile of trails that are 5 feet wide. I really do not want to widen the trails, since their current width gives an intimate feeling of being deep in a forest. The PT30 works on all our trails and turning around in 5 feet is no problem. Try that with a tractor. <br /><br />Unity Farm has many slopes, rocks, roots, gates, and narrow passages around outbuildings. I was able to drive the Terex through all of the them.<br /><br />This weekend, I'll move a few thousand pounds of wood and a few cubic yards of mulch around 15 acres. When I told the salesman that I had already moved 10000 pounds of manure, 10000 pounds of logs, and 10000 pounds of mulch with a wheelbarrow and wagon, he asked "are you nuts?". The answer to that question could be debated.<br /><br />Unity Farm was built by hand labor, but now that I'm almost 52 years old, I look forward to the automation as I move thousands of pounds around the property every weekend.<br /><br />Admittedly that Kubota tractor did look appealing, so I did buy one…for my desk.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigRv-kLah1UUMWzjjrqTdwkov7vtKV8wRxwo86MPtmkpclySAtSitIx2v2zdL0H9Ve7rF-3FlV6owIHDQ3nzF0UezVOJgyV6hqxbZYAsZS1qk0k4DTkJDHpEzbXqZDCSoGTP40ORY5KAdm/s1600/photo.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigRv-kLah1UUMWzjjrqTdwkov7vtKV8wRxwo86MPtmkpclySAtSitIx2v2zdL0H9Ve7rF-3FlV6owIHDQ3nzF0UezVOJgyV6hqxbZYAsZS1qk0k4DTkJDHpEzbXqZDCSoGTP40ORY5KAdm/s1600/photo.JPG" height="320" width="240" /></a></div><br />Another Unity Farm update. I lecture frequently at Harvard Business School and write for Harvard Business Review (HBR). My Harvard students and colleagues often asked me, "why didn't you go to 'B' school"?<br /><br />They're completely right and I'm going to correct this deficit by enrolling in a<a href="http://norfolkbees.org/index.php/beeschool"> nighttime executive 'B' school this semester</a>. <br /><br />I'll learn about Bee biology, site selection, hive manipulation, four seasons management, honey extraction, and disease control.<br /><br />In addition to my degrees from Stanford, UCSF, UCLA, Harvard, and MIT, I'll proudly add the 'B' school certificate to my CV this April.dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-33699043463876081532014-01-29T03:00:00.000-08:002014-02-15T02:37:00.250-08:00Management Lessons Learned from A Game of ThronesA Game of Thrones is the first novel in A Song of Ice and Fire, a series of high fantasy novels by American author George R. R. Martin.<br /><br />I rarely watch television, but for Christmas, my wife bought me Season 1 of <a href="http://en.wikipedia.org/wiki/Game_of_Thrones">Game of Thrones</a>, the HBO series inspired by the novels. Don't worry, this blog post will not contain any spoilers. <br /><br />Watching the characters jockey for power and influence reminded me of my experience navigating organizations over the course of my career. Here are my top lessons learned from the series:<br /><br />1. Doing the right thing does not always work<br /><br />I have strongly believed that the nice guy can finish first and that in the long term those with strength of moral character will triumph. In Game of Thrones, some of the moral characters are outfoxed by manipulative, cruel, and deceptive characters. One character notes "When you play the game of thrones, you win or you die." I have no plans to change my personal philosophy or approach to life, but it is interesting to reflect that some battles cannot be won with honor if your opponents are truly evil.<br /><br />2. There should be alignment of authority and responsibility.<br /><br />One character notes "The man who passes the sentence should swing the sword." It's easy for management to make decisions when someone else has to implement them. Over the course of my career, I've been careful to "<a href="http://en.wikipedia.org/wiki/Eating_your_own_dog_food">eat my own dog food</a>" using the products I'm responsible for creating, making hard decisions then executing them, and taking responsibility for consequences that even indirectly result from my actions. In organizations where there is a disconnect between authority and responsibility, chaos reigns if you lack authority to manage change in your areas of responsibility or if you have authority but are not responsible for your actions.<br /><br />3. You need to choose your goals and stick to them.<br /><br />One of the characters is torn between honor and family. He does not know whether to stay with his new colleagues (as he as sworn to do) or travel to aid his family in a time of war. He struggles with the decision and for a time pursues neither goal. Eventually he chooses honor and is "all in" with that goal, knowing that many others will assist his family and all will be well.<br /><br />4. Strategy matters.<br /><br />In the series, an extremely wealthy family attempts to win a war by being better resourced. Another family with fewer resources strategically outmaneuvers the wealthy family by building alliances and separating their forces into two contingents, using the element of surprise to achieve victory. Good planning is just as important as good execution.<br /><br />5. You can't predict the future, but you can react to events around you to make the future.<br /><br />One of the characters is a young and untested leader, willing to grow and make thoughtful decisions as she gains experience. Events occur around her beyond her control. She reacts to them calmly and in the best interests of others. Eventually circumstances change and she seizes the opportunity to move beyond her formal authority, creating loyalty with the informal authority derived from her unique abilities.<br /><br /><br />We all grow over time and engage in own Game of Thrones at a micro level as we journey through our careers. Many of the characters in Game of Thrones and in our workplaces are morally ambiguous. I live each day knowing that I cannot control the behavior of others, only my reaction to it. Guided by my values, I've been able to achieve little victories in the game of life.<br /><div><br /></div>dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-69960767030179993832014-01-23T03:00:00.000-08:002014-02-15T02:37:00.256-08:00Building Unity Farm - Winter FermentationsIt's the dead of winter in New England, with new snow on the ground and temperatures near zero. The animals are clustered together in their barn spaces and heated buckets are keeping their water liquid.<br /><br />There are many indoor tasks to do on the farm during winter - sharpening chain saw chains and other tools, reorganizing the workbench, ordering seeds, planning for Spring planting (we've been tractor shopping), and nurturing all the fermentations begun in the Fall.<br /><br />Our fermentations include 3 kinds of cider, mead, cyser (a mixture of cider and honey), vinegar, sourdough,sauerkraut, and fermented pickles. Here's an overview<br /><br />1. Cider, Mead and Cyser<br /><br />Although we <a href="http://geekdoctor.blogspot.com/2013/11/building-unity-farm-making-perfect-cider.html">bottled 4 cases of sparking cider in the Fall</a>, we still have 12 cases in the fermenters. Fermenter #1 is a Champagne Yeast fermentation of 11 different kinds of apples kept at 52F in our mudroom to prevent <a href="http://en.wikipedia.org/wiki/Malolactic_fermentation">Malolactic fermentation</a>. The malic acid in apples is a dicarboxylic acid with a sharpness/crispness that I like in a sparkling cider. Think of it as the flavor of a green apple. When I make sparkling cider, I add 6 grams/liter of dextrose at bottling to prime the cider for carbonation. The malic acid and dextrose create a harmonious flavor that's very refreshing. I typically have a 16 ounce bottle of sparkling cider with lunch on weekends. After 2 months of aging, the ph of this cider is 3.75 and the malic acid taste is very notable.<br /><br />Fermenter #2 is a Champagne Yeast fermentation of 11 different kinds of apples with added Malolactic bacteria culture. After two months, the ph of this cider is 4.15, much softer and smoother given that most of the malic acid has been converted to lactic acid, which has only a single carboxyl group. I'll bottle this cider uncarbonated - as still cider. Malolactic fermentation changes the flavor a bit, adding the kind of butteriness you taste in most Chardonnays.<br /><br />Fermenter #3 is a Champagne Yeast fermentation of 11 different kinds of apples with added Malolactic bacteria culture. The yeast has exhausted many of the nutrients in the cider due to a <a href="http://www.piltoncider.com/cider/keeving">Keeving process</a> I used during the initial fermentation. It's fermenting very slowly and I believe I will end up with a smooth cider with a small amount of residual sweetness. I'll bottle this cider uncarbonated as well. The ph of this Cider is 4.07.<br /><br />The taste among the three is remarkably different and we'll see which one is best once I bottle them in the Spring.<br /><br />The mead and cyser fermentations continue. At the first racking, the specific gravity of the mead decreased from 1.090 to 1.030, yielding 8% alcohol. The specific gravity of the cyser decreased from 1.085 to 1.010, yielding 10% alcohol. We'll continue fermentation until the Spring and bottle them uncarbonated in 375ml clear wine bottles once fully fermented to a specific gravity of 1.000.<br /><br />2. Apple Cider vinegar<br /><br />I separated 20 liters of hard cider from the other fermenting batches, <a href="http://www.motherearthnews.com/real-food/how-to-make-vinegar-at-home-zmrz14fmzmat.aspx">added mother of vinegar</a> and stored it in the basement, open to the air. When it is finished, the titratable acidity will be 5%. It's currently at 2% and has a remarkable flavor without being overpowering.<br /><br /><br />3. Sourdough<br />We use the <a href="http://www.kingarthurflour.com/sourdough/">King Arthur Starter</a> and keep buckets of <a href="http://www.kingarthurflour.com/blog/2012/04/08/maintaining-your-sourdough-starter-food-water-and-time/">active sourdough growing</a> in our mudroom.<br /><br />4. Sauerkraut<br />We use a 5 liter <a href="http://en.wikipedia.org/wiki/Fermentation_crock">Harsch crock</a> and weights with the following recipe<br /><br />3kg of cabbage<br />15 grams of salt<br /><br />Remove wilted outer leaves of cabbage head, and the stalk. Shred cabbage.<br /><br />Layer the cabbage, sprinkle some salt then press down with a fist until juice appears. Repeat until pot is full.<br /><br />Lay on the weights and if there is not enough juice, add cooled boiled salt water (15gm salt per liter ratio)<br /><br />Close lid, then add plain water to the rim (water trap)<br /><br />Leave pot at room temperature for 3 days until you hear some bubbling.<br /><br />Move to a cooler room for 4-6 weeks<br /><br />Move into large Ball jars in the refrigerator. Eat within a month.<br /><br /><br />5. Fermented Pickles<br /><br />We use a food grade 2 gallon bucket and a plate on top as a weight<br />2 pounds freshly picked firm, unwaxed, bumpy pickling cucumbers, often called Kirby<br />2 cloves spring garlic, sliced thin<br />1 dill flower, or 5 sprigs fresh dill or 1 teaspoon dill seed<br />1/2 teaspoon coriander seed<br />1/2 jalapeño, seeded and slivered<br />2 tablespoons salt<br /><br />Soak cucumbers for 30 minutes in a bowl filled with ice water to loosen any dirt. Slice the blossom end off each cucumber, which is opposite the stem end. If you aren’t sure which end is which, slice a little off each. Cut cucumbers into spears or chunks, if desired.<br /><br />Pack cucumbers into one or two clean quart jars. Tuck in garlic, dill, coriander and jalapeño, if using.<br /><br />Add salt to two cups boiling water. Stir until dissolved. Add two cups of ice (made with filtered water if yours is chlorinated). Stir well until the ice has melted and the brine is cool. Pour brine into jars, covering cucumbers.<br /><br />Loosely cap jars and place in a bowl or pan because the jars may leak during fermentation.<br /><br />Leave pickles on the counter to ferment. The brine will bubble lazily and become cloudy. Taste after 3 days, leaving on the counter another day or two if you want your pickles more sour, or refrigerating if they’re ready. They keep a month in the refrigerator.<br /><br /><br />It's time to put another log on the fire and listen to the subtle bubbling of our winter fermentations.<br /><br /><br /><br /><br />dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-24965552965038517862014-01-22T03:00:00.000-08:002014-02-15T02:37:00.261-08:00Advice to the New National CoordinatorKaren DeSalvo started as the new National Coordinator for Healthcare Information Technology on January 13, 2014. After my brief discussion with her last week, I can already tell she's a good listener, aware of the issues, and is passionate about using healthcare IT as a tool to improve population health. She is a cheerleader for IT, not an informatics expert. She'll rely on others to help with the IT details, and that's appropriate.<br /><br />What advice would I give her, given the current state of healthcare IT stakeholders?<br /><br />1. Rethink the Certification Program - With a new National Coordinator, we have an opportunity to redesign certification. As <a href="http://geekdoctor.blogspot.com/2013/10/rethinking-certification.html">I've written about previously</a> some of the 2014 Certification test procedures have negatively impacted the healthcare IT industry by being overly prescriptive and by requiring functionality/workflows that are unlikely to be used in the real world. One of the most negative aspects of 2014 certification is the concept of "certification only". No actual clinical use or attestation is required but software must be engineered to incorporate standards/processes which are not yet mature. An example is the "transmit" portion of the view/download/transmit patient/family engagement requirements. There is not yet an ecosystem for patients to "transmit" using CCDA and Direct, yet vendors are required to implement complex functionality that few can use. I completely support the idea of "transmit", but it should have waited until the ecosystem was mature enough to make it an attestation requirement. Another example is the use of QRDA I and QRDA III for quality reporting. CMS cannot yet receive such files but EHRs must send them in order to be certified. The result of this certification burden is <a href="http://www.healthit.gov/buzz-blog/ehr-case-studies/ehr-certification-numbers/">a delay in 2014 certified product availability</a>. Certification should focus on rigorous interoperability testing, using mature standards, in practical use cases, supported by the evidence and experience.<br /><br />2. Evaluate the collective timelines of Meaningful Use, ICD10-CM, ACA and the HIPAA Omnibus Rule - Thousands of pages of regulations are hitting the industry at the same time and it's clear that like healthcare.gov, haste will make waste. My suggestion - extend Meaningful Use Stage 2 Year One attestation by 6-12 months (not just delay Stage 3 a year as has already been done) to enable clinicians to install certified software, redesign workflows, be properly trained, and educate their patients about the new functionality available. I realize this may be a regulatory leap, but I've seen new rule making done as corrective action in the past. Although I believe ICD10-CM requires more testing (the CMS planned March testing is not enough) and most applications will not contain the clinical documentation improvement features needed for clinicians to adequately justify the new codes, most hospitals have put so much time and resources into ICD-10-CM projects that they cannot afford to extend the project beyond October 1. For ACA, re-evaluate quality measure submission requirements per point #4 below. For the HIPAA Omnibus Rule, rethink the accounting of disclosures scope and timing.<br /><br />3. Declare victory for Meaningful Use - Stage 1 of Meaningful Use was a phenomenal success. Adoption rates of good EHRs by hospitals and eligible professionals has tripled. Public health reporting and interoperability are accelerating. Awareness of security issues has markedly improved. Stage 1 was seen as a tide floating all boats. Stage 2 was greeted with less excitement. It exceeded the capacity of many organizations from a technology, policy, and workflow perspective. It has been described as a burden that has slowed innovation, consumed industry resources, and co-opted local agendas for quality improvement projects. However, it has many benefits and those gains can be captured with enough time. By the end of Meaningful Use Stage 2, hospitals and eligible professionals will have reached a breaking point in their capacity to absorb regulatory burdens, so we have to progress beyond 2017 very thoughtfully. If our policy goals are outcomes based, then we should offer a Stage 3 regulation which enables organizations to qualify for incentives if outcomes are achieved using IT as an enabler. We should not prescribe specific functionality for the EHR other than interoperability and security. As noted in point #1, focusing on certification and attestation for interoperability is reasonable as long as there are no "certification only" functions mandated. We should eliminate penalties for non-compliance with Stage 3 and return EHR innovation to customers and vendors. Meaningful Use will have succeeded if we capture the gains of Stage 1 and 2, then focus on Stage 3 incentives that drive us to better outcomes, rather than penalizing providers for not checking more attestation boxes.<br /><br />4. Fund pilots and research - We are on the cusp of a sea change in interoperability, population management, and clinical decision support. CCD led to CCDA which leads to FHIR for content summary exchange. The Direct protocol will evolve to a RESTful interface using OAuth/OpenID for trust fabric creation. However, we're not going to make the move to FHIR and REST unless pilots (followed by agile development of implementation guides) are funded to enable incremental progress. FHIR is too new and REST has too many industry skeptics. The pilots will create a tipping point which mitigates risk and enables progress. Also, two of the great challenges in informatics - automated quality measures (QueryHealth and HQMF) and nationally curated decision support (Health eDecisions) would benefit from pilots. In point #1 I noted that we need mature standards but at present our quality measurement and decision support standards are immature. If we pilot them and revise them, we'll mitigate risk and can consider the use of quality and decision support standards which are optimized for purpose in future interoperability certification.<br /><br />5. Continue the ONC convening function for standards, privacy/security, and hearings to capture lessons learned about adoption/implementation - ONC provides a very important and unique convening function in which issues can be discussed by multiple stakeholders. There will be an ongoing need for standards selection and revision, bridging the work of standards development organizations and clinical stakeholders. Privacy and security policy is informed and improved through national debate of the issues. Evaluating the successes and shortcomings of the EHR related regulations is important to future refinement. I suggest that ONC/CMS limit their regulatory focus on Meaningful Use requirements related to mature interoperability standards and privacy/security (as noted above), and focus much more on bridging gaps in five key areas: a) ONC versus CMS (certification versus attestation); b) HHS versus CMS (disparate quality measure and other reporting requirements within the HHS domain); c) the government versus market (vendors and providers); d) vendors versus providers; and e) providers versus patients. In practical terms, this would focus less on a core belief that 'all EHRs should do X, Y and Z' to a focus on 'given what we are learning about an ever-evolving market (e.g., new payment models, new delivery models such as Patient Centered Medical Home, new technologies, new patient engagement models, etc), what EHR interoperability needs, quality measures, and privacy/security safeguards are needed.'<br /><br />It's a fragile time at ONC when the excitement of the ARRA/HITECH funded grant programs has passed, many people have departed, and Congress is wary of IT projects in general.<br /><br />Karen is the right person for the job at this time in history, just as her predecessors were the right people for their eras. She can regain the trust of Congress, make midcourse corrections to the Meaningful Use program, and balance the burden/benefit on stakeholders. If she can rebuild a city's health system after Katrina, she can polish those elements of the ONC strategy that experience in the marketplace has deemed to be necessary.<br /><br /><br />dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-77023564863487687342014-01-16T03:00:00.000-08:002014-02-15T02:37:00.267-08:00Building Unity Farm - The Sounds of Unity FarmSince moving to the farm in April of 2012, I've posted many pictures of our efforts to create a working farm in Sherborn, Massachusetts. Although it's winter, the farm still bustles with activity. To give you a sense of what I experience every morning as I walk through the barnyard tending to the creatures, I carried an Olympus USB audio recorder with me on a recent morning.<br /><br />On the front of the farmhouse we have a rain chain in lieu of gutters that drains into a cistern to capture water. It was raining during my recording you'll <a href="http://mycourses.med.harvard.edu/ec_res/nt/36E335A4-5012-4EEA-93E1-4FEE487680C1/barnyard.mp3">hear my walk from farm house</a>, past the rain chain, to feed the guinea hens and ducks. <br /><div class="separator" style="clear: both; text-align: center;"><br /></div>After feeding the ducks and guineas I sat with the chickens for a few minutes and fed them scratch grains. <a href="http://mycourses.med.harvard.edu/ec_res/nt/22885E43-B01B-4905-B86E-DE6EA15C8D5B/chickens.mp3">Our two roosters decided to compare their voices</a>.<br /><br />The duck pond was thawing as the temperatures warmed and I spent a moment clearing the ice so that the birds could enjoy <a href="http://mycourses.med.harvard.edu/ec_res/nt/4D9273D2-A5FB-4242-A43B-CEE767A0B2B0/pond.mp3">open flowing water</a>.<br /><br />I brought fresh lettuce from the hoop house to the birds and placed it in a large rubber bowl so all the animals could enjoy a taste of summer during the winter. <a href="http://mycourses.med.harvard.edu/ec_res/nt/32E0E783-BBB1-4993-9DD3-58B63F013AA9/guineas.mp3">The guineas squawked with joy</a> as they crunched the leaves.<br /><br />The northern border of Unity Farm is mixed forest and wetlands. The western border is the Dowse apple orchard. The southern border is another farm. The eastern border is the CSX rail line (map below) for slow moving freight trains that travel between Framingham and Foxboro. At 7am, 12:30pm, and 2:30pm and 11:30pm, we hear the <a href="http://mycourses.med.harvard.edu/ec_res/nt/9EC781F9-07AA-4C2A-BBC1-A052763944F1/train1.mp3">gentle rumble of a freight train in the distance</a>, 10 acres away through our forest. Here's what the morning train sounds like from the barn.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8Pn-joQaVjwILem8cqt4KiWLlY28xcUcGZlTWmRR0-zWNb2v6RhyphenhyphenvN8MnIN78DagJTYC2IEZNNPi7oh5J3h1SvwTDW0JZMPKfvURcUTcM9Y-zJKn1JTZkiS7g44lZLi8e8GCBEyWkkfW4/s1600/train.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8Pn-joQaVjwILem8cqt4KiWLlY28xcUcGZlTWmRR0-zWNb2v6RhyphenhyphenvN8MnIN78DagJTYC2IEZNNPi7oh5J3h1SvwTDW0JZMPKfvURcUTcM9Y-zJKn1JTZkiS7g44lZLi8e8GCBEyWkkfW4/s1600/train.png" width="311" /></a></div><br /><br />Every season brings new sights and sounds on the farm. This spring many migratory birds will return and nest at Unity Farm. This summer, we'll experience the birth of several baby alpaca. The Fall brings the rustle of falling leaves. More sound posts to come!<br /><br />dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-47879561090504790632014-01-16T02:32:00.000-08:002014-02-15T02:32:28.945-08:00Health and Fitness Spas in South Africa<div id="article-content" style="text-align: justify;">
<div style="text-align: justify;">
Unique health spa destination</div>
<div style="text-align: justify;">
Why is a South Africa spa
experience so relaxing and effective is the fact many of the luxury city
chic spas are located in some of the most magnificent natural
environment on the planet. Several overlook tinkling streams, ocean
seascapes and mountain vistas while others are placed in mystical
man-made grottos, hewn and crafted from the mountain side!</div>
<div style="text-align: justify;">
South
Africa health spas aren't limited to the large city centres. Most of the
rural holiday destinations offer wellness, well being and vitality as
an extra allure to the more tried and tested facilities, points of
interest and activities. The Cape Winelands, the Midlands of Kwa-Zulu
Natal, the Garden Route and South Africa's bush are visitor 'hang-outs'
with spectacular health spas on tap.</div>
<div style="text-align: justify;">
Golf estate health spas</div>
<div style="text-align: justify;">
Golf
in South Africa yearly draws in thousands of visitors from all over the
globe and most of the perfect golf locations in South Africa have
luxury spas on the property, providing visitors a well-earned respite
from the travails and challenges of the course.</div>
<div style="text-align: justify;">
The glistening
Garden Route venue of the Presidents Cup, Fancourt Resort, Country Club
and Golf Estate includes a health spa dominated by a heated Roman Bath
with spectacular views of the Outeniqua Mountains whereas Pezula,
Arabella, Erinvale, Selborne and Pearl Valley, all situated in popular
tourist destinations, are but a handful of golfing locations in South
Africa which offer indulging health spa treatments as a welcome addition
to the general golfing experience.</div>
<div style="text-align: justify;">
Bush spas</div>
<div style="text-align: justify;">
Southern
Africa is a renowned big game safari destination there are a large
number of privately owned games reserves, national parks and animal
sanctuaries providing a perfect bush encounter.</div>
<div style="text-align: justify;">
In an effort to
stay competitively priced, numerous top-end luxury game lodges have
secluded and remote wilderness bush spas presenting a range of health
spa remedies as an extra attraction of a Big 5 safari bundle.</div>
<div style="text-align: justify;">
Etali
Lodge in Madikwe offers mini-spa treatments, whereas the Bushman's
Kloof Wilderness Reserve in the Cedarberg, the Falaza Game Reserve in
Hluhluwe and the Sabi Sands Earth Lodge all possess magnificent spas
situated in the tranquillity of the Africa bush!</div>
<div style="text-align: justify;">
Arranging a luxury spa holiday in South Africa</div>
<div style="text-align: justify;">
Tourists
who wish to mix a perennial South Africa holiday experience with
wellness, well being and vitality can do so with ease. Online South
African booking websites provide entries of accommodation that offer
refreshing health spa treatments in spectacular surroundings.</div>
<div style="text-align: justify;">
Source
a stylish inner-city hotel, luxury game lodge or top-end golf estate
with health spa amenities anywhere in the country from the comfort of
your office or living room and then book an unforgettable luxury South
African spa holiday today!</div>
</div>
dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-87241310812415732022014-01-15T03:00:00.000-08:002014-02-15T02:37:00.272-08:00The Roles I PlayAs 2014 begins, I marvel at the evolution of the CIO role from 1997 to 2014. Gone are the days when my role was to serve as technical expert, configuring web servers, optimizing data bases, or simplifying code. Gone are the days when product decisio nmaking depended on software architecture expertise to ensure scalability, reliability and security. Gone are the early wins of the "bold moves" like replacing Lotus Notes with Exchange, Novell with NT, Sybase with Microsoft SQL, and client/server with web applications.<br /><br />Here are a few examples of the roles I play today from the past few weeks<br /><br />1. Rethinking a challenging project by ensuring all stakeholders understand the key roles/responsibilities assigned during project formation i.e.<br /><br />Defining the business champion<br />Defining the executive sponsor<br />Defining the role of IT<br />Defining the role of the project manager<br />Defining the support model<br />Defining the responsibility for creating, managing, and maintaining interfaces<br />Assigning responsibility for workflow/process definition<br />Assigning responsibility for vendor relationship management<br />Writing the governance committee charter<br />Defining the communication plan for internal and external customers<br />Defining unit testing and integrated testing responsbilities<br />Defining the training/education plan<br /><br />2. Convening local government and provider stakeholders to agree on a single approach for public health reporting that aligns meaningful use stage 2 requirements, healthcare information exchange timelines, and affordable care act planning. We needed consensus on scope, timing, and technical details so that local government efforts are complementary rather than competitive to the regulatory "must dos" of 2014<br /><br />3. Presenting the BIDMC Enterprise IT strategy to senior leaders of the hospital and professional groups, so that all stakeholders understand the options, the decisions make thus far, and linkage between business requirements/IT tactics.<br /><br />4. Serving as master of ceremonies for the statewide health information exchange public demonstration, ensuring all involved institutions were showcased to highlight their strengths.<br /><br />5. Assisting with the development of new policies and procedures such as those involving privacy, healthcare information exchange and use of social media in healthcare<br /><br />In 2014, the my work role has evolved to convener, communicator, mediator, navigator, and load balancer instead of technician, architect, programmer, informatician, and clinical expert. Not that the evolution is bad. In the modern era, we all have about 5 careers in our lives. What's amazing to me is how many careers I can have without changing my position as CIO!<br /><br />I recently wrote a column for Information Week, <a href="http://www.informationweek.com/healthcare/leadership/healthcare-it-leadership-boiling-the-frog/d/d-id/898877">Boiling the Frog</a> describing some of the challenges all CIOs face as their roles evolve. As we begin 2014, I have the recovery time afforded by the holidays behind me and I'm approaching my role with new optimism. The chaos and stress of 2013 is behind me. I'm ready to thrive as I focus on using my evolving skills to make those who report to me as successful as possible.<br /><br />Over the holidays I completed two books which will be published in the next few weeks, codifying everything I've learned in my CIO roles over the past 20 years. One is a 400 page edited, revised, and indexed reflection on the themes of my blog. I'll be doing a book signing at HIMSS. The other is a 250 page fictional thriller co-written with a prominent Italian healthcare system CIO and containing many elements inspired by the IT events I've experienced over the past few years. More to come as they are published in paper and e-book form.dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-75614616897554891402014-01-09T03:00:00.000-08:002014-02-15T02:37:00.342-08:00Building Unity Farm - Thinking about AutomationEvery year at Unity Farm, I move 10000 pounds of manure, 10000 pounds of logs (18 inch segments), 10000 pounds of wood chips, and thousands of pounds of snow. I've done this to date using a hand cart and wheelbarrow. I turn 52 in a few months and its time for automation.<br /><br />But, what's the ideal device? We have hills, forests, meadows, mud, ice, and grass.<br /><br />A tractor such as the <a href="http://www.kubota.com/product/B3200/B3200.aspx">Kubota B3200HSD</a> seems reasonable with industrial R4 tires that provide traction without too much damage to underlying soil. John Deere offers a competitive model of tractor, the <a href="http://www.deere.com/wps/dcom/en_US/products/equipment/tractors/compact_utility_tractors/3000_series/3032e_compact_utility_tractor/3032e_compact_utility_tractor.page">3032E</a>. <br /><br />However, many of the trails at Unity Farm are narrow and the manure access is via a crusher rock access path about 5 feet wide. Are there alternatives?<br /><br />Many have recommended a compact track loader such as the<a href="http://www.bobcat.com/loaders/models/track/t110"> Bobcat T110</a>.<br /><br />Others have recommended the <a href="http://www.terex.com/construction/en/products/new-equipment/compact-track-skid-steerloaders/compact-track-loaders/pt30/index.htm">Terex PT30</a><br /><br />Track loaders provide maneuverability and good hill climbing capabilities, but they can be rough on grass.<br /><br />My answer - I have to experiment with each machine. Since they vary in price from $16000 to $25000 (0% financing for 5 years may be available), it's best if I "test drive" them.<br /><br />For $200 per day, I can rent these devices from local dealers. I can move manure, wood, rocks, and mulch. I can run them up and down hills in a variety of conditions.<br /><br />To me, the device design/engineering is important but access to dealer service is also critical.<br /><br />The Kubota/Terex dealer is 12 miles away. The Bobcat dealer is 35 miles away. The John Deere dealer is 35 miles away.<br /><br />I'll report back on my experiments with moving, hauling, and transporting around Unity Farm. I welcome input from others on comparing Kubota, John Deere, Bobcat and Terex.<br /><br /><br />dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-91764684751875307852014-01-08T03:00:00.000-08:002014-02-15T02:37:00.415-08:00The Next Phase of Healthcare Information ExchangeToday, Massachusetts Governor Deval Patrick will launch the next phase of healthcare information exchange (HIE) in Massachusetts - “<a href="http://www.youtube.com/watch?v=u3YstYQHD3U&feature=youtu.be">Commonwealth Interconnected: Mass HIway Query and Retrieve</a>”<br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiYNzHSt2yKe5n3vHBdTiio3Y7tRaiMSvgZBVgPY8BBqwbtQ5NKFEeOiStLBIVf1lF1kC68lbDW5ITs27oLueh2DIV3p61QHXHbO1yrS7SrjHNkR6LzdU3P6iR33_j8pxxV9YV9jaG7n7t/s1600/Haynes-IMG_8086.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiYNzHSt2yKe5n3vHBdTiio3Y7tRaiMSvgZBVgPY8BBqwbtQ5NKFEeOiStLBIVf1lF1kC68lbDW5ITs27oLueh2DIV3p61QHXHbO1yrS7SrjHNkR6LzdU3P6iR33_j8pxxV9YV9jaG7n7t/s1600/Haynes-IMG_8086.jpg" height="98" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div>In Phase 1 of our state HIE project, we focused on the Meaningful Use Stage 2 Direct protocol, enabling transition of care summaries, public health reporting transactions, and labs to flow over a state operated secure infrastructure.<br /><br />In Phase 2, we solved a much harder and more complex problem - the pulling of records in real time from physician offices and hospitals where patients have opted in to disclose their records to other caregivers.<br /><br />This required the engineering of several components<br />*A state wide master patient index for patients who opt in, storing name, gender, date of birth and other demographic data elements<br />*A state wide consent registry indicating the medical record numbers and locations where patients have opted in to disclose their data to caregivers<br />*A portal which enables providers to securely login and view patient medical record locations<br />*A viewer which enables secure retrieval of medical records from organizations which support real time data display<br />*An electronic medical record request system for those organizations which support a request/release by the medical records department workflow.<br />*Full audit trails of all activity - an accounting of disclosures<br /><br />Today a multi-organizational team will demonstrate an Emergency Department visit by a febrile, confused, elderly gentleman. His records are scattered over many hospitals and clinician offices. Treatment in an emergency room is accelerated, more aligned with patient/family care preferences, and is safer with more information. We'll demonstrate how a single institutional record based on one episodic visit can be very different than a lifetime continuous record which includes the entire patient experience with healthcare. We'll show several near misses with diagnostics and therapy that could have caused harm, increased expense and reduced quality.<br /><br />Today is the launch of the service. The state's master patient index and consent registry (collectively called the relationship locator service) will be populated as patients consent to be included. 57 organizations including providers, public health, health plans, local HIEs and clinical registries are already part of the Massachusetts HiWay and all will be working hard in 2014 to expand the use of the new services.<br /><br />I can imagine a day in the next few years, when all patients in the Commonwealth, with their consent, benefit from secure, coordinated care. My mother suffered a major medical error in California because of inaccessible primary care records. I truly believe that my 20 year old daughter, attending Tufts University, will see significant reduction in preventable harm in Massachusetts during her 20's.<br /><br />Let the safety begin!<br /><div><br /></div>dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-76251404801955662862014-01-04T06:59:00.000-08:002014-02-15T02:37:00.485-08:00Baby, It's Cold OutsideFor those who not have experienced <a href="http://www.weather.com/news/weather-winter/winter-storm-hercules-state-state-impacts-20140101">Winter Storm Hercules </a>, it's currently -10F at Unity Farm (not wind chill, that's -15F). We have 10 inches of new fallen snow.<br /><br />As I've written about previously, all the animals have protection from wind and water. Wall mounted heaters are protecting them from frostbite. At dawn we gave the alpaca and llama large bowls of alfalfa mixed with molasses. The chickens and guinea fowl ate hot oatmeal mixed with dried cherries. The ducks got a warm duck soup of chopped greens and warm water. The dogs got an extra helping of their favorite dog food. The rabbit got a very sweet banana.<br /><br />Here are a few photos at -10F from Unity. Yes, an iPhone 5S works well at that temperature, although fingers using the phone do not last long.<br /><br />I added bricks to the top of the bee hives to prevent the covers from blowing off. We added sugar feeders to the inside of each hive and replaced the hive opening with a very small "winter" front door. A capping of snow insulation is keeping them warm. <br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEig4_WunjkW-83QQNtJhDgBrEF1zLaAm2Ttl4itVKqN-N90itzXjTFF8gUjUxcx49IlKrlgO0MHazuVW4b95gFUYrTaek-ddrxhWHE5vbclI7gRpBP7jg7R0WEsJy-mX-mAPQWZsQDZNmbG/s1600/bees.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEig4_WunjkW-83QQNtJhDgBrEF1zLaAm2Ttl4itVKqN-N90itzXjTFF8gUjUxcx49IlKrlgO0MHazuVW4b95gFUYrTaek-ddrxhWHE5vbclI7gRpBP7jg7R0WEsJy-mX-mAPQWZsQDZNmbG/s400/bees.jpg" width="300" /></a></div><br />We refilled every bird feeder, ensuring our juncos, chickadees, bluebirds, wrens, finches, titmice, woodpeckers, cardinals, and nuthatches have maximal nutrition.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQ9x6aGPXleTJa1uGsL72otq42ioYqv11xqTZSHz9YE5eV2DCi9uZDjWlpTA_uymoyNxjJUU08TUitJmF729ZwWuMXhda63YkwCbK2rSdT1_8nKIs3GLCdlpqlEfUHxSP-9dG_Sqn3aFgP/s1600/birdfeeder.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQ9x6aGPXleTJa1uGsL72otq42ioYqv11xqTZSHz9YE5eV2DCi9uZDjWlpTA_uymoyNxjJUU08TUitJmF729ZwWuMXhda63YkwCbK2rSdT1_8nKIs3GLCdlpqlEfUHxSP-9dG_Sqn3aFgP/s400/birdfeeder.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">The cider house is keeping all the apple picking and beekeeping equipment safe from the elements.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYc8agTGAcI2DtJOM4Gl8LxR87mgoUrG-nhp4ddOU2pUU7E1mUixtIv1ig0TvSiYxlZTNEyX1FbCjeGOKeNmRG6VCwQMjzYnoJ9iyJFBM16aoYfq1LF58D_tQtN7WPo9f8_LKtFOKXYu6b/s1600/cider.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYc8agTGAcI2DtJOM4Gl8LxR87mgoUrG-nhp4ddOU2pUU7E1mUixtIv1ig0TvSiYxlZTNEyX1FbCjeGOKeNmRG6VCwQMjzYnoJ9iyJFBM16aoYfq1LF58D_tQtN7WPo9f8_LKtFOKXYu6b/s400/cider.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">We shoveled all the paths and gates for easy access to the coops and paddocks.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpMZrWUnAclxS_WE-QFT3LcDvcRnwDEPY26RYy77zlMoVe4M4BE_HvBTwuZjXCWkR9B5HaWbG9OFPX_4-b5uvd7DJHGkw4RFmBDZd7YA0e_1GDAQC2U5VHLzb5hh_yjNuDztt1rB4xTKOq/s1600/coop.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpMZrWUnAclxS_WE-QFT3LcDvcRnwDEPY26RYy77zlMoVe4M4BE_HvBTwuZjXCWkR9B5HaWbG9OFPX_4-b5uvd7DJHGkw4RFmBDZd7YA0e_1GDAQC2U5VHLzb5hh_yjNuDztt1rB4xTKOq/s400/coop.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">The hoop house is a balmy 28F, keeping our winter vegetables growing by trapping the heat of the sun.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzDOiwM5yrd3IJnMCuTiN19DMmVaz-jCebBdpWmKgZfJ1WwQOjW_OfV7OiyzIs7yC10UkIrwx0zxAosO2FQsrY4Qrfklbp_pXUgb2G93knuTpHCDtTtW376sqRNeW8cJdrkluIsyBEkWi7/s1600/hoop.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzDOiwM5yrd3IJnMCuTiN19DMmVaz-jCebBdpWmKgZfJ1WwQOjW_OfV7OiyzIs7yC10UkIrwx0zxAosO2FQsrY4Qrfklbp_pXUgb2G93knuTpHCDtTtW376sqRNeW8cJdrkluIsyBEkWi7/s400/hoop.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">The blowing snow drifts created <a href="http://en.wikipedia.org/wiki/Zastrugi">Zastrugi</a> in the orchard </div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9pZMyKGVd1oKn7Hs7zZwR2dhiCdIJxUNanka4gNtPAMYl5SaGFY87LPotYZBLn7FUTkqloIpwZQ2Og75VMyqmzdvi8hZgpuFhQxmAoeDmL9zyA_PdDSICHVpAGXsXtB-RruFBrw2aMnXt/s1600/orchard.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9pZMyKGVd1oKn7Hs7zZwR2dhiCdIJxUNanka4gNtPAMYl5SaGFY87LPotYZBLn7FUTkqloIpwZQ2Og75VMyqmzdvi8hZgpuFhQxmAoeDmL9zyA_PdDSICHVpAGXsXtB-RruFBrw2aMnXt/s400/orchard.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">The pastures are covered with a blanket of snow. After 2 years of moving snow, mulch, and manure with a hand drawn wagon, I'm finally considering a tractor.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPTO9OTh1fL1HQqsg9HW1hzmrlPN1LFendpoflqz3kJmitMgIugv1nz6Qsw9HaRV9H0qF1VORGoTQSw2HZ3g4Lr0tts7GHYVM5hlwEAOCBFehQsuCAyizCyJbj5r7Z3H2MVFssNjYEka_G/s1600/pasture.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPTO9OTh1fL1HQqsg9HW1hzmrlPN1LFendpoflqz3kJmitMgIugv1nz6Qsw9HaRV9H0qF1VORGoTQSw2HZ3g4Lr0tts7GHYVM5hlwEAOCBFehQsuCAyizCyJbj5r7Z3H2MVFssNjYEka_G/s400/pasture.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">Shiro, our 120 pound Great Pyrenees male, has very big paws for scrambling through snow.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsJW-uf2OS8E3Mf32g-IDU5RS9pcpjo_clhRodGO5dTb8uibNAYXens4G-KgILl-k016TjzF8ZlvnQhDtya-sVxUqypl643lJmqRf_IubloCqlzMp-yD9bHLBThGft5MweE-GXDuy4Fs0V/s1600/paws.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsJW-uf2OS8E3Mf32g-IDU5RS9pcpjo_clhRodGO5dTb8uibNAYXens4G-KgILl-k016TjzF8ZlvnQhDtya-sVxUqypl643lJmqRf_IubloCqlzMp-yD9bHLBThGft5MweE-GXDuy4Fs0V/s400/paws.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">The duck pond is frozen and covered with snow, although the water is still circulating below the surface. The ducks bathe in their 50 gallon stock pond that is heated to 40F.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcefI28MlVYxBdlRRKzGINN5-y9C91CYrtpOXOkBKB5u6CIi5asmxWY31CrSYMOdTbM_P2zB7MCZ884PMwM3UsVwK1Tx44qMZsBD83ukBKXqxeUZIjD5JQG4WUx2YBVLnXjWQietxK9yAQ/s1600/pond.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcefI28MlVYxBdlRRKzGINN5-y9C91CYrtpOXOkBKB5u6CIi5asmxWY31CrSYMOdTbM_P2zB7MCZ884PMwM3UsVwK1Tx44qMZsBD83ukBKXqxeUZIjD5JQG4WUx2YBVLnXjWQietxK9yAQ/s400/pond.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">We dug out the garden shed to access all our snow management tools.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJT0n0TEW_np67BY6k6wPfKBt0OEUlXl1QpT224TO0Sueu8x4e4Zrqph-MCPgiK3oRv8Jgmqxgo4SD5JTF5fvLByIrkSC6WRFnT0TPkT_DF7m5ROlt-tafAWj-qVQcelHRb6ZqNqRYs5VP/s1600/shed.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJT0n0TEW_np67BY6k6wPfKBt0OEUlXl1QpT224TO0Sueu8x4e4Zrqph-MCPgiK3oRv8Jgmqxgo4SD5JTF5fvLByIrkSC6WRFnT0TPkT_DF7m5ROlt-tafAWj-qVQcelHRb6ZqNqRYs5VP/s400/shed.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">Shiro kept a close eye on everything during the storm.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnUxfHop73Q7WmheLXXYm5aq6w-5tMIy28-f1iMVfcy6Y_1-KJJD4N6j0y2EONl7HOm8_nkMYnM-ArVG6alQKkLeZ4uwzjuDpNbToyHSrWHgZ_T7OougEDHGTU29nDcjeUQl_AT5pjs7ym/s1600/shiro.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnUxfHop73Q7WmheLXXYm5aq6w-5tMIy28-f1iMVfcy6Y_1-KJJD4N6j0y2EONl7HOm8_nkMYnM-ArVG6alQKkLeZ4uwzjuDpNbToyHSrWHgZ_T7OougEDHGTU29nDcjeUQl_AT5pjs7ym/s400/shiro.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">We removed the roof from the mushroom house to keep it from collapsing under the weight of ice and snow.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrGZvdU0I1JrJoSnC_9dzHqiFg6UIxBuWdrVXF8d7isRmM7WPOwHAcE1qiPkM8rn81BNSNGdUueErasDhGrsismPfFqpLOXnaoMc5wXf0CHzxHy48hPhTz9T-KUSLwU498LNvRD_P0kzAD/s1600/shitake.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrGZvdU0I1JrJoSnC_9dzHqiFg6UIxBuWdrVXF8d7isRmM7WPOwHAcE1qiPkM8rn81BNSNGdUueErasDhGrsismPfFqpLOXnaoMc5wXf0CHzxHy48hPhTz9T-KUSLwU498LNvRD_P0kzAD/s400/shitake.jpg" width="400" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">We have three mushroom "laying" yards where fruiting logs are kept for harvest. At this time of year, the only creatures exploring the laying yards are deer, rabbits and foxes.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbXO3-XLvEUdRtCybvxBcBJnyEL7Wklsrgr3vsAarsOqLHkgC7TvBkr4y7M7IB3-5MwKsxvjXNe0B-zHxmbFS37hgxasPSV_1jkyrFWOhk8kYXNmDLDiKmlBv5Pq9GrlU2DDMhbLdV1E0u/s1600/totem.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbXO3-XLvEUdRtCybvxBcBJnyEL7Wklsrgr3vsAarsOqLHkgC7TvBkr4y7M7IB3-5MwKsxvjXNe0B-zHxmbFS37hgxasPSV_1jkyrFWOhk8kYXNmDLDiKmlBv5Pq9GrlU2DDMhbLdV1E0u/s400/totem.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">The dogs are begging for a run on the trails, but at the moment only deer are running through the 10 inches of loose powder.</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgW8sb9lIJG5bjL2CR4vKRxAAwBG-XNziOF8Pt3U4SYtUF-_kPn2y56dRxhlOhrRwM3D8ThHulVgu0lRcCGdA46lHqFTs4hvi3KFeBkvprBunTbP66Cox7ThTN8krcv8lVwFExpD8JdStVU/s1600/trail.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgW8sb9lIJG5bjL2CR4vKRxAAwBG-XNziOF8Pt3U4SYtUF-_kPn2y56dRxhlOhrRwM3D8ThHulVgu0lRcCGdA46lHqFTs4hvi3KFeBkvprBunTbP66Cox7ThTN8krcv8lVwFExpD8JdStVU/s400/trail.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">I've split 8 cords of wood for heating this winter. We'll use half a cord during the duration of Hercules and the freezing days to follow.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNeVdqK6Aw_MWtwuLWMdk3-E8c-dZxXRUYkN7nH1Y_GBm5TymVfL95U4s3WGnOkl6YRCzeUE-CmrDtzW8BXspwYAWBaZ5s9CuTfK9jxCcYI1ekNiUFNvv8NBjIqMoHwkCYSav26BKn2cat/s1600/wood.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNeVdqK6Aw_MWtwuLWMdk3-E8c-dZxXRUYkN7nH1Y_GBm5TymVfL95U4s3WGnOkl6YRCzeUE-CmrDtzW8BXspwYAWBaZ5s9CuTfK9jxCcYI1ekNiUFNvv8NBjIqMoHwkCYSav26BKn2cat/s400/wood.jpg" width="300" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">Stay warm!</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;"><br /></div><br />dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-84343401565905492332014-01-02T03:00:00.000-08:002014-02-15T02:37:00.557-08:00Building Unity Farm - Making Mead and Cyser<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkQfcA_3qWZza4uIUxHrUcrmTmyV_FYPuS8R2Lxy7pFFq2FC5XN04wpELFCusxlvfzkJlaLgDHVVU6joppQwjL1pzd8dIbIZ9EmupO6UrGzvie3Di-C4tqQg4RVo73QeGx4tO6wYKq1u02/s1600/photo.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkQfcA_3qWZza4uIUxHrUcrmTmyV_FYPuS8R2Lxy7pFFq2FC5XN04wpELFCusxlvfzkJlaLgDHVVU6joppQwjL1pzd8dIbIZ9EmupO6UrGzvie3Di-C4tqQg4RVo73QeGx4tO6wYKq1u02/s200/photo.JPG" width="200" /></a>The entire family visited Unity Farm for the holidays. After all the gift giving, merry making, and <br />yuletide time by the fire was over, what should a family do at a farm with apples, honey, fermentation equipment (there's a basic chemistry lab in the cider house), spring water, and microbiology know-how? Make mead of course!<br /><br />Mead was the earliest fermented beverage created by man - evidence of honey and fermentation products begins about 9000 BC. Mead figures prominently in Hindu writings, the work of Aristotle, and the Old English poem Beowulf. <br /><br />There's a new vocabulary to learn when deciding how to make Mead.<br /><br />"Show" Mead - a higher alcohol, full flavored mead made with more honey and less water<br />"Small" Mead - a lower alcohol, lightly flavored mead made with more water and less honey (Queen Elizabeth the First enjoyed a very dilute mead)<br />Melomel - mead with added fruit or fruit juice<br />Pyment - a melomel made with grapes and often herbs. You could call it a honey-fortified wine<br />Cyser - a melomel made with apples. You could call it a honey-fortified hard cider<br />Zythos or Braggot - a mead fortified with malt. You could call it a honey-fortified beer<br />Morath - a melomel made with mulberries<br />Metheglin - a mead made with herbs or spices. The name means "Mead of the Glen". Some believe it is the root of the term "medicine"<br />Rhodomel - a metheglin made with roses<br /><br />At Unity Farm, we tend to prefer our beverages fermented dry. We often create both sparkling and still versions of our beverages, but I only make still mead after a bad experience with exploding bottles as a mead maker in my 20's. Here's the approach we used during the holidays:<br /><br />Unity Farm Mead<br /> 3 quarts water from our 600 foot deep well<br /> 3.5 cups Unity Farm Orchard Honey (wildflowers and clover)<br /> 1 teaspoon acid blend (citric/malic/tartaric acids)<br /> 5 grams Redstar Pasteur Champagne yeast<br /> 6.25 grams Go-Ferm yeast nutrient in 125cc's of 110F water<br /> 10 grams of Fermaid-K<br /><br />Heat the water to 160F, add the honey and acid blend. Simmer for 10 minutes and do not boil. Skim any foam from the top. Pour into a 2 gallon sterilized fermenter (we use food grade buckets with a drilled lid and airlock, pictured above). Take a ph or specific gravity measure if you wish. Our 12/29/13 batch had a specific gravity of 1.090 and a ph of 3.43, giving us a <a href="http://www.honeycreek.us/specfic_gravity_table.php">potential alcohol level</a> of 12%<br /><br />Add 6.25 grams of yeast nutrient to 125cc's of 110F water. At 104F add the yeast and wait 15 minutes. Cool 100cc's of the honey/water solution to 104F and add it to the yeast solution. Wait 15 minutes. The resulting yeast solution will be frothy with new yeast growth. <br /><br />When the honey/water solution in the fermenter is 104F add the yeast solution. Place in a room with a constant temperature in the low 60's for slower, more flavorful fermentation. <br /><br />After 1 day, add 5 grams of Fermaid-K<br /><br />After 1 week, add 5 grams of Fermaid-K<br /><br />After 2 weeks, rack the solution with a racking cane into a sterilized gallon jug and seal it with an airlock. Leave very little air space in the jug (1/4"). Top up with water if necessary. After 2 months, sterilize the mead with 50 parts per million of potassium metabisulfite, then bottle and age for 6 months before drinking.<br /><br />Unity Farm Cyser<br /> 1 quart water<br /> 2 cups Unity Farm Meadow Honey (wild asters and japanese knotweed)<br /> 1 teaspoon acid blend (citric/malic/tartaric)<br /> 1 cup black tea (steeped 3 minutes at 200F)<br /> 2 quarts Unity Farm unfiltered Apple Cider (made from 11 types of apples)<br /> 1/2 teaspoon pectic enzyme<br /> 5 grams Redstar Pasteur Champagne yeast<br /> 6.25 grams Go-Ferm yeast nutrient in 125cc's of 110F water<br /><br />Heat the water to 160F, add the honey, acid blend and tea. Simmer for 10 minutes and do not boil. Skim any foam from the top. Pour into a 2 gallon sterilized fermenter. When the mixture has cooled to 110F, add the cider and pectic enzyme.<br /><br />Take a ph or specific gravity measure if you wish. Our 12/29/13 batch had a specific gravity of 1.085 and a ph of 3.56, giving us a potential alcohol level of 11.3%<br /><br />Add 6.25 grams of yeast nutrient to 125cc's of 110F water. At 104F add the yeast and wait 15 minutes. Add 100cc's of the honey/cider/water solution to the yeast solution. Wait 15 minutes. The resulting yeast solution will be frothy with new yeast growth. <br /><br />Add the yeast solution to the fermenter. Place in a room with a constant temperature in the low 60's for slower, more flavorful fermentation. <br /><br />After 1 day, add 5 grams of Fermaid-K<br /><br />After 1 week, add 5 grams of Fermaid-K<br /><br />After 2 weeks, rack the solution with a racking cane into a sterilized gallon jug and seal it with an airlock. Leave very little air space in the jug (1/4"). Top up with water if necessary. After 2 months, sterilize the mead with 50 parts per million of potassium metabisulfite, then bottle and age for 6 months before drinking.<br /><br />Although we've not enjoyed the flavor of commercial melomels, we will create our own blueberry, raspberry, and elderberry melomels this summer when the berries are ready.<br /><br />Mead is an acquired taste and you will want to experiment with different styles to find the right mead for you. Hence I recommend 1 gallon batches that enable you to evaluate each recipe variation but not create an overabundance of something you'd prefer not to drink.<br /><br />Happy mead making!dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-77724731675065358032014-01-01T03:00:00.000-08:002014-02-15T02:37:00.628-08:00The Year That Was 2013As the year drew to a close, I was interviewed by many trade publications about the key themes that shaped 2013. Here's my own version of the notable events of 2013.<br /><br />1. Meaningful Use changed the EHR landscape<br />Regardless of your political affiliation, there is little debate that EHR adoption in the US achieved a tipping point in 2013. Here are our Massachusetts statistics from the 2013 Massachusetts Medical Society survey<br /><br />The current overall percentage of EHR use is 79% (N=201, CI=5.6) and 82% of those using EHRs have had access to this technology for more than 2 years. Extrapolated to the estimated 18,000 clinical physicians in the state, that would leave less than 3,500 clinical providers without access to EHR systems (3% of respondents indicating that they are no longer in practice).<br /><br />Broken down by practice size adoption rates are:<br />1-9 Physician practices made up 66% of respondents and had an adoption rate of 75%<br />10-25 Physicians practices made up 13% of respondents and had an adoption rate of 96%<br />26-75 Physicians practices made up 6% of respondents and had an adoption rate of 100%<br />>75 Physicians practices made up 12% of respondents and had an adoption rate of 97%<br /><br />2. Healthcare Information Exchange developed great momentum<br />Meaningful Use Stage 2 and more importantly the Affordable Care Act motivated organizations to implement push (via Direct and HISPs), pull (via regional and state HIE activities) and view (among clinical affiliates) interoperability for care coordination and population health. As a CIO, I'm no longer the lone voice driving interoperability top down, it has become a bottom up demand.<br /><br />3. Security and privacy became Board-level issues<br />Meaningful Use, compliance requirements, and enterprise risk assessments elevated security and privacy issues to top priority for many organizations. CIOs are hiring new security staff, enhancing capabilities, and expanding budgets to address increases in threat sophistication and volume.<br /><br />4. Self built EHRs became increasingly rare<br />Partners Healthcare and MD Anderson adopted Epic. Intermountain Healthcare adopted Cerner. That leaves Beth Israel Deaconess and the Marshfield Clinic among the few healthcare organizations building applications to enhance innovation and reduce cost. An unintended side effect of Meaningful Use Stage 2 certification criteria was that provider self built systems, niche specialty applications, and small EHR vendors all became rare.<br /><br />5. Innovation slowed as the regulatory combination of ACA, ICD-10, MU2, and HIPAA Omnibus rule dominated the agenda for IT organizations.<br /><br />The work I've done on Natural Language processing, Google Glass, advanced analytics, workflow enhancement, and patient/family engagement was limited to nights/weekends and the strength of will of selfless volunteers who innovated outside the workday.<br /><br />As <a href="http://geekdoctor.blogspot.com/2011/11/job-of-cio-content-verses-context.html">Meg Aranow guest posted on my blog in 2011,</a> the content of being a CIO in 2013 continued to be great, but the context became even more anxiety-provoking . Demand exceeded supply, anxiety/tension escalated, and budgets became even more constrained (except for selected security/compliance projects, which are often seen as burdensome rather than beneficial by customers). The holidays brought a welcome reduction in post traumatic stress disorder symptoms for many CIOs I know. However, on the positive side, I've always felt that times of great struggle are opportunities for greatness. We are living in the most transformative time for healthcare in the US, and the worsening CIO stress is just a side effect of accelerating change for all healthcare stakeholders. I recently wrote about the <a href="http://www.informationweek.com/healthcare/leadership/healthcare-it-leadership-boiling-the-frog/d/d-id/898877">mitigations we need to consider to get through each day</a>.<br /><br />Personally, 2013 was a combination of emotional highs and lows. My father died in March. My mother entered a new chapter in her life requiring resilience and new skills. My wife's cancer is in remission although she still experiences the side effects of chemotherapy, peripheral neuropathies and muscle spasms, that impact her activities of daily living. My daughter thrived at Tufts University in 2013, maintaining her own apartment, living independently, and viewing the world with increasing sophistication.<br /><br />Unity Farm continued to grow in 2013 with 11 chickens, 10 ducks, 29 guinea fowl, 11 alpaca, 1 llama, 2 Great Pyrenees Mountain dogs, 3 cats, and 1 rabbit in perfect health. 2013 was the year our orchard was born, the cider house was built, our duck house/pond was created, and we established a regular routine for efficiently managing all 15 acres of woodland, pasture, and wetland. We obtained various licenses and certifications to begin selling our jams/honey/cider/mushrooms/vegetables and learned a great deal about producing organic, handcrafted products.<br /><br />The combined responsibilities of leading IT for a growing ACO, assisting several countries with IT strategic planning, working on US national standards, championing state healthcare information exchange adoption, and being a Harvard Professor strained my endurance at times, especially early in the year when I made 5 visits to California around the time of my father's death. Trips to China, Japan, Taiwan, and London were all important, but required boundless energy to ensure my day jobs were fully supported while I was half a world away. 2014 will have much less travel than 2013.<br /><br />I turn 52 in a few months and as I reflect on the year that was 2013, I can say it was one of the most difficult on the journey thus far. However, at the end of the year I feel the trajectory heading into 2014 is right. The healthcare environment will still undergo tectonic shifts but my family, friends, and colleagues will make it navigable. I will reaffirm my quest for equanimity in all difficult situations, my veganism, and my balance of work/farm life. May 2014 be happy and healthy for all of you and enable you to make a difference.<br /><div><br /></div>dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-15230869110631355472014-01-01T02:31:00.000-08:002014-02-15T02:31:51.969-08:00Mental Health and Fitness - Down's Syndrome<div id="article-content" style="text-align: justify;">
<div style="text-align: justify;">
There is much more understanding nowadays of Down's Syndrome.</div>
<div style="text-align: justify;">
Once
a baby was born displaying the obvious physical signs, the future for
both mother and child was considered to be a difficult one and for the
baby, possibly a short one. The life of a person with Down's and the
immediate family was burdened with the social stigma associated at one
time with this condition for which there is no known cure.</div>
<div style="text-align: justify;">
The
idea was entrenched that it was caused by the mother becoming pregnant
in the later of her childbearing years. However, modern research
demonstrates this is not always the case although it is often a factor.
The main medical cause is seen to be the additional chromosome that
causes distinct physical and mental impediment.</div>
<div style="text-align: justify;">
Physically the
baby is born with certain characteristics and these of course can range
from minor degree to extreme in flatness of the face and back of the
head, slanted slit eyes, and the hands showing unusually small little
finger and only one transverse hand crease instead of the normal three
main creases. The muscular tone is missing and often the body is too
relaxed, and the heart muscle and other organs also can show defect.</div>
<div style="text-align: justify;">
The
condition is a total one involving the brain and body with slowness or
retardation of both intellectual capacity and physical development.
These can be improved and to a varying degree depending upon the care
that follows up to and beyond puberty when sexual instinct is usually
strong. This can cause additional problems and embarrassment to family
or those caring for them. However so much is dependent upon the special
care and education the child receives from the mother in particular.</div>
<div style="text-align: justify;">
Encouragement
is given to Down's patients staying within the family home and engaging
in family life as much as possible. Most babies develop very loving and
affectionate personalities but there are also extremely difficult cases
of aggressive nature which can be modified when they become involved in
some positive creative craft skills or have a chance to develop their
talents.</div>
<div style="text-align: justify;">
Assisting children who are mentally handicapped by having
Down's syndrome is intensive and demanding. Only loving parents and
carers who possess extreme compassion, patience and devotion undertake
this responsibility successfully and can balance their duties and
sacrifices with their own personal needs in life.</div>
<div style="text-align: justify;">
Usually life
expectancy is shorter than normal but many children who have enjoyed
special care and are accepted into an appropriate simple lifestyle can
live happily and overcome many limitations to develop into fine and
intelligent citizens.</div>
</div>
<div style="text-align: justify;">
Sally Janssen is a writer and educator who from an early age
trained in Raja Yoga--that branch of the ancient science that deals with
the mind and its complexities. She subsequently gained an international
reputation for her skills and her wisdom in the training of the mind.</div>
dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-34792061738641933422013-12-25T03:00:00.000-08:002014-02-15T02:37:00.699-08:00Building Unity Farm - A White Christmas on the FarmIt's Christmas at Unity Farm and the temperature outside is 12F. All 100 animals are fed, watered, and their living quarters are cleaned.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_T3Jjb89lThPXNu19KFiO9_bh1GiFHbOwiy0ZyAYAcYrNhHJ9imkeD6tehXM5iuo5vhyphenhyphenpMplttOPle2tkhhABWG5VOr1M2j7lwpCRLCNvoB6Xmd8tVVGGyl0FkW3Yn4kQzgsfIKzsWG8h/s1600/winter.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_T3Jjb89lThPXNu19KFiO9_bh1GiFHbOwiy0ZyAYAcYrNhHJ9imkeD6tehXM5iuo5vhyphenhyphenpMplttOPle2tkhhABWG5VOr1M2j7lwpCRLCNvoB6Xmd8tVVGGyl0FkW3Yn4kQzgsfIKzsWG8h/s400/winter.jpg" width="400" /></a></div><br /><br />The orchard and cider house have been put to bed. I racked the last 60 liters of our fermented cider into three 20 liter Spiedel tanks and inoculated two of them with malolactic bacteria (Oenococcus oenii) to soften the acids and round out the flavor. We'll bottle still and sparking cider in the Spring.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSULQUX9EpsAHcQL-OPxPwvvIP20UTGA6fDys64YnThtEhdNcA1py-__rcqkJ38uU_t4aHQt-v4G2hSUxVKzXuhndWy-mN7EBy_3FBn2o4wPa3_Q4QakF9C_kf9NZuxVKnXPeCFvOfxWxe/s1600/photo.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSULQUX9EpsAHcQL-OPxPwvvIP20UTGA6fDys64YnThtEhdNcA1py-__rcqkJ38uU_t4aHQt-v4G2hSUxVKzXuhndWy-mN7EBy_3FBn2o4wPa3_Q4QakF9C_kf9NZuxVKnXPeCFvOfxWxe/s400/photo.JPG" width="400" /></a></div><br /><br />The hoop house is filled with salad greens, thriving in the balmy temperatures of cold frames and planting blankets. The soil temperature of our 15 raised beds is between 50-60 in winter. <br /><br />The ducks are now 12 weeks old and have begun to venture beyond their duck pen and spend the day with the chickens and guineas.<br /><br />The guinea fowl have decided that the duck pond is a spa and enjoy washing their feet in the running water.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigmENJI5H66KTqT1mrwgnbCDMzFEWqO9-WFJwwzWJTc-li0pP6yPU5LP7PXJowSA5zGg6o70efVP_F0PNsC4QgFJ6yqTHlPGrUNfBterDuhmSsSsNa-FkO1DrBqzK_XeLOtRJzOekwaiX4/s1600/guinea.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigmENJI5H66KTqT1mrwgnbCDMzFEWqO9-WFJwwzWJTc-li0pP6yPU5LP7PXJowSA5zGg6o70efVP_F0PNsC4QgFJ6yqTHlPGrUNfBterDuhmSsSsNa-FkO1DrBqzK_XeLOtRJzOekwaiX4/s400/guinea.JPG" width="300" /></a></div><br /><br />The mushroom logs are dormant in the cold but the oyster and shitake cultures within them continue to thrive. We've removed the roof of the shade house so that it does not collapse under the weight of snow and ice.<br /><br />The farmhouse is the focal point for entire family - my wife, my daughter, my mother, my daughter's boyfriend, his parents, and my father in law are all gathered for a vegan feast.<br /><br />A cheery fire is burning in the heath - a mixture of ash and maple woods from the 10 cords I've cut and split this season.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjd80Do2fDv-ieOzx1ICmbvX3RfgSMCT81bAOqC7xiiL51xJSlpqhoC3fdNgc7IHRX28tdMTGShB4Xrm2eqg2zNN5fk-0C8XM3rUr-i8DoI5Jtk8GdDWLiK1TRy-WBKz0MFma6fnhBEuW4x/s1600/fire.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjd80Do2fDv-ieOzx1ICmbvX3RfgSMCT81bAOqC7xiiL51xJSlpqhoC3fdNgc7IHRX28tdMTGShB4Xrm2eqg2zNN5fk-0C8XM3rUr-i8DoI5Jtk8GdDWLiK1TRy-WBKz0MFma6fnhBEuW4x/s400/fire.jpg" width="400" /></a></div><br /><br />2013 has been a year of high highs and low lows. This is the first Christmas without my father. My wife's cancer is gone, my daughter's semester at Tufts was very successful, and all the creatures at Unity Farm are thriving.<br /><br />In a world with decreasing resources, an increasing population, and accelerating change, there's a tendency to lose civility. My own experiences this year have reinforced the importance of maintaining equanimity in the face of adversity. As the year draws to a close, there is no regret for anything I've done or not done, professionally or personally. The holiday season in 2013 will be an excellent wrapper around one of the most tumultuous years of my wife.<br /><br />As 2014 approaches, I can only hope that our happiness persists, regulatory burdens diminish, and breakthrough innovations become our standard work.<br /><br />Happy Holidays to all!<br /><div><br /></div>dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-62470156045015176292013-12-19T03:00:00.000-08:002014-02-15T02:37:00.770-08:00The December HIT Standards CommitteeThe December HIT Standards Committee focused on patient generated data, image sharing, patient matching, and the 2014 work plan, ensuring we select the necessary standards to support Meaningful Use stage 3 policy goals.<br /><br />We began the meeting with a discussion by<a href="http://www.healthit.gov/facas/sites/faca/files/CT_WG_18_Dec_13%201pptx.pptx"> Leslie Kelly-Hall of patient generated healthcare data </a>- structured and unstructured questionnaires plus patient provided medical history such as medications, allergies, and problems. The key discussion was an evaluation of the standards maturity and the level of adoption of the standards suggested for patient generated data exchange. Recommendations included Direct for data transport, CCDA for content capture, LOINC/SNOMED for vocabulary capture, and Continua implementation guides for devices. As a followup the Consumer Technology Workgroup will list examples of CCDA templates that can be used to support patient generated data use cases. Continua will provide us a list of the named standards so that we can validate the maturity and adoption of Continua's implementation guides. We will also ensure that the CCDA templates include the appropriate vocabularies that will enable incorporation of patient generated data into EHRs.<br /><br />Next, <a href="http://www.healthit.gov/facas/sites/faca/files/HITSC_ClinicalOps_121813.pptx">Jamie Ferguson presented an overview of the standards selected for radiology and non-radiology image exchange</a>, including associated reports. Our challenge was to provide a parsimonious collection of constrained standards for consumer and professional applications in tightly coupled (modality to PACS), and loosely coupled (web-based, cloud hosted image exchange) architectures. We all agreed that we need to be very careful when writing certification criteria to avoid optionality such that vendors will be forced to implement many different standards (the "OR" of meaningful use becomes the "AND" of certification).<br /><br />Next, <a href="http://www.healthit.gov/facas/sites/faca/files/PtMatching_HITSC%20Dec%2018%202013.pptx">Lee Stevens presented the work done to date on Patient Matching</a>. We all look forward to ONC's final recommendations for optimizing data quality, selecting matching algorithms (deterministic or probabilistic), and choosing data elements that will provide reasonable sensitivity and specificity. <br /><br />Finally <a href="http://www.healthit.gov/facas/sites/faca/files/HITSC%20Workplan%20Dec%2018%202013_MC.pptx">Doug Fridsma a straw man plan for reorganizing the HITSC workgroups</a>, spreading the work ahead across more people to enhance our agility and reduce volunteer burn out. All thought the reorganization and work plans were reasonable but suggested two additions. First, we'll need another workgroup that focuses on research/creating a learning healthcare system. Second, we need to ensure that each workgroup reserves time for future planning and does not limit its scope to selection of incremental standards to solve today's urgent needs. We'll implement future planning by adding it to each workgroup's agenda and implementing a matrixed management approach for communication and coordination of future planning among the workgroups.<br /><br />The FY14 work ahead looks well prioritized and categorized. Our next meeting will be in February when we'll be joined by the new National Coordinator for Healthcare IT, <a href="http://www.modernhealthcare.com/article/20131219/NEWS/312199959/breaking-new-orleans-health-commissioner-to-lead-onc">Karen DeSalvo </a>dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0tag:blogger.com,1999:blog-2694963579127891296.post-84141001914827779092013-12-18T03:00:00.000-08:002014-02-15T02:37:00.841-08:00Become a MountainWhen I was 16 years old I wrote a short collection of poems. The cover page listed a few youthful notions that would become my life long guiding principles:<br /><br />"Be wary of artificial limits and self-compromise<br />If the world praises mediocrity, don't seek praise<br />Be true to yourself<br />You make your own destiny"<br /><br />Some of these ideas were written in response to high school teachers who told me that my goals were unachievable - I should not ask "will I" but "can I".<br /><br />Over my career, I've worked with and for many people. Along the way I've encountered many styles - those who lead by intimidation, those who lead by collaboration, and those who lead by inspiration. Some have asked me to stretch my limits and others have asked me to constrain them.<br /><br />When I recently reviewed the words I wrote at 16, I reaffirmed that at my core is the notion that I should live each day to the fullest, performing at what I consider the very edge of my capabilities, then add one more thing. It's the motivational equivalent of "no pain, no gain".<br /><br />My wife recently sent me a quote that summarizes this passion even more eloquently:<br /><br />"I am here for a purpose and that purpose is to grow into a mountain, not to shrink to a grain of sand. Henceforth will I apply all my efforts to become the highest mountain of all and I will strain my potential until it cries for mercy. Og Mandino"<br /><br />When I was resident in emergency medicine in Los Angeles, I was on the front line during some of the most violent years in gang-related shootings. It was the era before residency duty hour limits and I recall one particularly rough weekend on the trauma service that required 36 hours in the operating room. I became so dehydrated that my urine crystalized and formed kidney stones. I'm not suggesting this was a good thing or should ever occur during residency, but it does illustrate the potential of the human will during a crisis.<br /><br />A few years ago, my daughter read a short story by Kurt Vonnegut called <a href="http://en.m.wikipedia.org/wiki/Harrison_Bergeron">Harrison Bergeron </a> (it was also made into a short film called 2081) in which absolute equality was achieved by putting weights on athletes, loud earphones on academics, and masks on beautiful people, artificially limiting their performance.<br /><br />Sometimes we encounter this in our work lives with less dramatic but real suggestions that we perform at a level below our capabilities.<br /><br />My advice - you'll encounter many people in life who feel more comfortable when surrounded by grains of sand. However, in a humble, quiet, and selfless manner, become a mountain. Stretch yourself beyond any internally or externally induced self-compromise and limits. <br /><br />We only live once and no one has ever put this on their tombstone:<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNNWDz8okvbguYSnu8wGedV5s9EjBZdXhETmO8019BEzuZMKPQYd1pP9gA7DZQ-Ppw6ge56rCFWsa89z6jcoehX9arMXYBZtC65QTvC3SZnfHHpQ7d6Nfugprlb1yU7OtcP2mzpEzfEmqV/s1600/aristotle.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="393" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNNWDz8okvbguYSnu8wGedV5s9EjBZdXhETmO8019BEzuZMKPQYd1pP9gA7DZQ-Ppw6ge56rCFWsa89z6jcoehX9arMXYBZtC65QTvC3SZnfHHpQ7d6Nfugprlb1yU7OtcP2mzpEzfEmqV/s400/aristotle.png" width="400" /></a></div><br /><div><br /></div>dssadsdshttp://www.blogger.com/profile/17763154659366171389noreply@blogger.com0