Building Unity Farm - Creating the Hoophouse

This summer, as we cleared land for the orchard, we graded a level surface for a 21x48 foot hoophouse to extend our growing season and enable us to produce greens for our table and the animals year round.

We purchased the steel for the structure from Ledgewood Greenhouses in New Hampshire and sought the help of River Valley Fencing to build it.   Although we built the 10x30 foot shade house for mushroom cultivation ourselves, creating the 21x48 foot structure required tools and equipment we do not have.

The back of the structure is T-11 plywood.  The front is lucite.   The top is a 6 millimeter UV resistant plastic that lasts about 5 years.

Inside the hoophouse, we built 16 raised beds - 87x48x12" so that we have room for 2 foot aisles.

We dug a foot deep foundation underneath the raised beds and filled it with 12 cubic yards of composted alpaca/llama manure (we have plenty).   When then filled the raised beds with a combination of compost, moss, and vermiculite.

The hardest part of project was creating a water supply that would work in the winter.   We dug a four foot trench from our well equipment to the hoop house and attached a yard hydrant http://geekdoctor.blogspot.com/2012/07/cool-technology-of-week.html with a 4 foot burial depth.    Since the frost line in Massachusetts is 36-42 inches, water will flow throughout the year, even in the depth of winter.   We also ran an electrical line in the same trench to power the temperature controlled fans in the hoop house.

Next week we'll plant our Fall/Winter vegetables - lettuces, spinach, kale, chard, and  garlic.

As we approach the end of 2013, the building phase of the farm is coming to an end.   We've finished the hoop house, the mushroom growing area, the orchard, the cider house, and the duck house this year.   We're now ready to spend the next 30 years growing, learning, and using everything we've created.

I've never considered myself a prepper http://en.wikipedia.org/wiki/Survivalism but if the zombie apocalypse does come, we'll be able to sustain ourselves from the farm around us.

The CareFwd Conference

Yesterday, I joined a panel at the CareFwd conference discussing the innovations needed in healthcare today.

I highlighted 5 areas:

1. Meaningful Use Stage 2
Need novel patient engagement tools - existing healthcare business to consumer web and mobile products lack a value proposition and are hard to use
Need healthcare information exchange capabilities - data liquidity is increasingly important for care coordination
Need quality measurement innovations - modern EHRs must provide decision support at the point of care to ensure quality measure criteria are met

2.  ICD-10
Need Computer Assisted Coding - no clinician can remember 170,000 codes
Need Clinical Documentation Improvement - in an ICD-10 world, a clinician needs to include enough information to justify a highly granular diagnostic code
Need to seamlessly link the problem list, the documentation and the bill - surviving future audits will require a level of integration that auto-populates the problem list and suggests an appropriate billing code, all based on interpretation of what the clinician documents

3.  HIPAA Omnibus Rule
Support for enhanced security including identity management, network access control, security information and event management - these components are foundational to a mature security program
Need BYOD solutions - personal devices are here to stay.   We need to manage them centrally with minimal user impact
Need novel breach detection - inappropriate internal access can be a more significant risk than external threats

4.  Affordable Care Act
Need novel business intelligence approaches that leverages unstructured data - more than half of the typical medical record is text.   We need to be able to use it for decision support
Need prospective and retrospective reminders - turning data into information, knowledge and wisdom is the only way to achieve gains in quality, safety and efficiency
Need care management and population health - we need to achieve wellness and continuous preventative care, rather than episodic illness care

5.  Secure cloud computing resources in general
Need to sign business associate agreements - cloud solutions must include indemnification for privacy breaches
Need third party audits - we need to understand the physical and logical protections in place at cloud hosting sites
Need 99.99% reliability - the cloud has been described as "your mess, outsourced, with less reliability".   We need high reliability

To all the entrepreneurs out there - these are products and services I'll be buying over the next year.

Rethinking Certification

Over the weekend, I finished editing my new book - "Geekdoctor: Life as a CIO" which will be published this Winter.     I was re-reading historical blog posts and reflected on "What Makes Me Happy"

In that post I suggested things to avoid in order to retain your optimism:

"1.  Unplanned work that increases scope without a change in resources or timeline

2.  Needless administrative or bureaucratic processes imposed by those who are not actually doing the work"

As BIDMC prepares for certification of its inpatient and ambulatory applications, I've had the opportunity to review every test script and assess the burden/benefit of certification.    Although attestation criteria are great, the approach to certification could benefit from a reboot to remove scope, reduce resources required for certification, and substantially simplify the process.

Here are a few recommendations:

*Scripts need less optionality -  Although we want to create a smooth trajectory from one stage of meaningful use to another by offering historical, current, and future focused options such as CCR, CCD, and CCDA summaries for attestation, such optionality forces certification to include full testing of all of them. It's a bit like saying that an IT department is forced to support iPhones, Android devices, Windows phones and Blackberries just because someone might buy one.   My organization has put limits on what can actually be used, so I really do not want demonstrate functionality for certification that no clinician will ever need.

*Scripts need more modularity - The Massachusetts State HIE supports the Direct specification for SMTP/SMIME and XDR, enabling any provider to connect to the State HIE via an EHR or HISP.   We want to achieve modular certification of the state HIE so that any clinician can attest to Stage 2 using the State HIE to support transmission of transfer of care and encounter summaries.    However, the script for certification requires a demonstration of CCDA generation and transmission, ensuring no HIE can achieve certification since HIEs do not produce CCDAs, EHRs do.    Our only alternative is to build a mini-EHR so that the HIE can demonstrate all the functions and all the options for every section of the script.    That creates unnecessary burden and stifles innovation.

*Scripts should be less prescriptive - Patient and family engagement is one of my major focuses.  The View/Download/Transmit script requires that very significant new functionality be added to EHRs and describes precisely how it must work.   I wonder if requiring some basic building blocks would be better, then let the market innovate as patients and providers demand new products.

*Certification should not include more functionality than is needed for attestation - there is no attestation requirement for problem list reconciliation or allergy list reconciliation but there is a certification criteria requiring demonstration of these functions using a fully electronic approach.    The standards for allergy clinical models are still in progress, so we're requiring functionality in products that is not required for attestation and lack mature standards.

*The standards committee suggested that some standards not be part of meaningful use stage 2 because of lack of maturity - QRDA for quality reporting, LDAP for certificate discovery, and CDA for cancer registry reporting.    Just as with PQRS XML in stage 1, developers will have to incorporate these into certification, but they are unlikely to be used because there is no ecosystem to support them.

*User Centered design is motivated by the desire to have safe, functional EHRs.   The certification script requires that each developer produce 8 documents with 11 sections describing focus groups with users.   At BIDMC clinicians design software for clinicians via an agile, continuous improvement process.   It's not clear how creating these 8 documents adds value to that process.    Maybe self-developed applications should have a different process than vendor applications?

What is the goal of certification?  I would argue that we want secure interoperability between EHRs.

Maybe the certification process should focus on the capacity of an EHR to follow Postel's principle  "be conservative in what you do, be liberal in what you accept from others"

Certifying organizations would not be prescriptive about user interfaces, workflow, or exhaustively test every variation of every option.   Instead, they would certify that an EHR can securely send a precisely formatted clinical summary and securely receive a compliant but less than perfect clinical summary.

That worked for email, browsers, and the foundation of the internet, so why not EHRs?

ONC has a done a great job with very limited time and resources.   These observations are meant as planning ideas for the future as we refine regulations based on the experience of real world implementation.

Building Unity Farm - The Ducks Arrive

Today, 10 ducks, born on Monday, arrived at Unity Farm.    Here are the details

1.  Two Fawn and White Runner Ducks

2.  Two Rouen

3.  Two Blue Swedish

4.  Two Welsh Harlequin

5.  Two Chocolate Runner Ducks

Just as with our chickens and guinea fowl, each duck has their own personality and temperament.   For prospective duck buyers, here's a behavior chart by breed.

We'll keep them in our indoor brooders for 4 weeks, then move them to the duck house.

Last weekend, we built a 10x18 pen and 4x8 enclosure to keep the ducks safe from predators and warm in stormy weather.   Ducks prefer living outdoors and do not mind wet conditions (i.e. duck weather).   Snowy, windy days with temperatures approaching zero can cause frostbite to their webbed feet, hence benefit of an enclosure.    Next weekend, I'll dig an electrical trench and wire the enclosure with a flat panel warmer that will keep the space 10 degrees warmer than the ambient temperature in the winter.

The pen includes a 50 gallon swimming trough, water and food.

We'll learn more about duck behavior as they age.   I stand ready to built ramps in and out of the pen and the enclosure to make the area more duck friendly.

Ducks are truly magnificent creatures and I look forward to seeing them run around the farm during the day.

If anyone asks me if my ducks are in a row, I can now respond that my ducks are doing very well indeed.

The HL7 Annual Meeting

On Monday, I had the honor of keynoting the HL7 Annual meeting in Cambridge, MA.   I used these slides.

I began with an overview of the Standards work in progress in the HIT Standards Committee and the S&I Framework.   Then, I offered personal comments (not representing the Standards Committee) as to where I believe healthcare Standards need to evolve.

My major point was this - Why did the web grow an exponential pace?  We had transport (HTTP) and content (HTML) that anyone could use without significant training to create and consume information.   Healthcare has always viewed itself as different, requiring more complex standards to address every possible edge case.   What we need is HTTP and HTML that is good enough for healthcare.  

Fast Healthcare Interoperability Resources (FHIR) using JSON is the simple HTML for healthcare that does not require knowledge of the HL7 RIM

The work of Dixie Baker and the Privacy and Security Workgroup evaluating the combination of REST/Oauth2/OpenID indicates that REST is the HTTP for healthcare.  

Although CCDA and Direct are a reasonable starting point and will exist for many years, FHIR/JSON and REST/OAuth2/OpenID is where we need to be.

The September HIT Standards Committee Meeting

The September HIT Standards Committee focused on image exchange, scenario-based certification,  the Food and Drug Administration Safety and Innovation Act (FDASIA) , and an important discussion about setting standards priorities for FY14.

This was Farzad Mostashari's last meeting.   He shared his worries and offered us advice:
*Do not slow  implementation of FY14 standards.  We've worked too hard to get this far
*Offering more time for Meaningful Use Stage 2 attestation may be appropriate
*New standards are coming but we can make progress today.  Do not let the perfect be the enemy of the good
*We need to create the standards and interoperability that people want, have value, and are appropriate for purpose

We began the meeting with a presentation by Jamie Ferguson about the image sharing testimony we've heard thus far.   They key points are that different standards are needed for view/download/transmit use cases, evolving DICOM standards such as Web Access to DICOM Objects  (WADO RS)  and STore Over the Web (STOW RS) may meet many of these needs, and other countries have models we should study (such as Scotland).

We next heard an update on scenario based testing from Scott Purnell-Sanders. The current approach to certification breaks up clinician workflow into discrete scripts which many not demonstrate usability in actual clinical practice.  The notion that an EHR should be certified based on a seamless clinical workflow, supporting the functions required for meaningful use, is a real improvement in certification design.

Jodi Daniel provided a policy update, focusing on the Food and Drug Administration Safety and Innovation Act (FDASIA) .  The FDASIA Working Group, chaired by David Bates, did a remarkable job outlining a framework that balances innovation and risk reduction.

The remainder of the meeting with devoted to an FY14 Standards Workplan discussion by Doug Fridsma which reviewed an activities matrix listing current HITSC priorities, S&I framework initiatives in progress/planned, and HL7 ballots in progress.   They key question for the HIT Standards Committee is how to balance scope, time, and resources over the next year to deliver those key standards needed to support national priorities- Care Coordination, Improving Quality, Engaging Patients/Family, and Population Health.    Using the matrix, we will prioritize the most important and most urgent projects over the next few weeks.

Building Unity Farm - The Mushroom Harvest Begins

Last night was 39 degrees and we're wrapping up all the projects of summer since fall officially begins this Sunday.

We've picked our early apples (Honeycrisp and MacIntosh) and are watching our late apples (Empire) ripen quickly.

Our blueberries and raspberries are already preserved.

Squash, beans, and root vegetables are picked and sitting in our drying racks.

We're finishing the construction of our hoop house for winter vegetables (more about that next week).

All our summer babies have been born - 73 guinea fowl in 3 batches.   We've moved the 4 week olds into the coop and sold the second batch to a farm near Rhode Island.  The third batch will be going to a farm in central Massachusetts.

We'll have alpaca babies next summer.

Before the weather turns too cold, we're finishing the inoculation of the logs we cut this year and harvesting mushrooms from logs we inoculated in the spring such as the oyster mushrooms shown above.    We have three mushroom growing yards on the farm.

The first is in a grove of pine trees just outside our wetland border.   It's cool, shady and moist.    It has 48 poplar logs inoculated with two species of oyster mushrooms

PoHu - This oyster strain is the most “wide range” of Oyster strains with multiple fruitings throughout the growing season, including summer. PoHu is a heavy producer and grows many ocher to white colored mushrooms in thick clusters.

Grey Dove - This Oyster strain is prolific and reliable. Steel blue pins slowly change into silvery grey as the cap matures. The shape is classic Oyster; graceful stem with a shell-shaped cap.

The second area is in a fern grove under the largest pine trees on the farm.  It's a little drier and warmer.    It has 96 poplar logs inoculated with four species of oyster mushrooms.

Italian - A mild flavored mushroom with a thick stem that grows in gorgeous clusters. Mature mushrooms have a delicate brown colored cap with beautifully contrasting white stems.

Blue Dolphin - Also known as the “Fall Fruiting Tree Oyster,” this strain undergoes a lovely metamorphosis from the frosty blue pins through the pewter gray clusters of the mature mushrooms. Blue Dolphin is a prolific fruiter in cooler weather, especially after the first near-frost temperatures in autumn. It needs near freezing temperatures to stimulate fruiting.

Golden - A luminous citrine yellow mushroom with a tangy flavor perfect in small quantities as an edible garnish. This mushroom lightens in color when sautéed to provide a fungal feast for both palate and eye. Golden Oysters fruit naturally in late spring and again in late summer - perfect for outdoor summer cultivation.

Polar White - A lovely icy white, cool weather Oyster mushroom that fruits in the fall. This strain has dense, porcelain white caps and is incredibly flavorful.

We recently added 110 Shitake logs to the fern grove - ten logs for each species described below.

The third area is our shade house - 85% shade cloth 30 feet long, 10 feet wide and 10 feet high.   It has 11 species of Shitake in 165 logs

Bellwether -  In both spring and fall, it fruits with an abundance of large, thick, cup-shaped mushrooms with layer upon layer of white lace ornamentation.  It's a highly productive, cool season fruiter.

Chocolov -  This strain produces medium sized, round, almost glossy capped mushrooms the color of dark chocolate.  It fruits late in the fall.

Miss Happiness - A gorgeous late fall fruiting  strain with uniformly round brown caps.

Snow Cap - Produces beautiful, uniform, thick fleshed caps tufted with white lacey ornamentation. Heaviest fruiting occurs early spring and late fall.

Double Jewel - This strain produces large, dense, beautifully ornamented mushrooms, often in attractive paired clusters, inspiring the name.  Fruits naturally in the spring and fall.

Native Harvest -  Native Harvest gives a late fall flush; an added bonus for the Thanksgiving table!

West Wind - West Wind features large, thick, first flush mushrooms, and heavy yields. West Wind is also slightly more drought tolerant than other strains.  Fruits naturally in the spring and fall.

WR46 - A popular commercial strain that offers heavy first flushes and quick log recovery after fruiting.

Night Velvet - This warm weather strain produces big, plump mushrooms that are like picking apples.

WW44 - This strain produces mushrooms with thick, round, honey colored caps which are perfectly shaped and maintain high quality during periods of excessive humidity.

WW70 - This warm/cool weather strain has a late summer - late fall fruiting period. It is also one of the most beautiful, with dark caps and lots of contrasting ornamentation.

Finally, in our shade house we also inoculated 12 logs with Lion's Mane.

Last night's dinner included Italian oyster mushrooms sautéd with our farm grown onions.

Of course the woodlands at Unity Farm yield their own native mushrooms, many of which are edible - boletes, morels, chanterelles, coprinus,  and maitake (hen of the woods).   Some, like this parasol mushroom, are strikingly beautiful.