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What is Hormonal Acne? Pictures of Hormonal Acne

Have you been wondering if you suffer from hormonal acne?  Have you tried everything but nothing seems to work?  Well, hormonal imbalance could very well be the problem.  Hormonal acne is caused by a hormonal imbalance, which can stem from a variety of issues.  Teenagers going through puberty are highly prone to acne...why?  Well, during puberty a teens hormones are all over the place.  Unfortunately, some adults are just as prone to acne due to hormonal imbalances.  Hormonal acne can be linked to the following:

  • Birth control pills
  • Specific foods (dairy, gluten, etc., get checked for intolerances)
  • Stress levels
  • Certain medications (consult your doctor)
  • Environmental toxins
  • Eating disorders

To get checked for a hormonal imbalance, consult with your physician who can determine if you have a hormonal imbalance that could be causing hormonal acne.

Want to know what hormonal acne looks like?  Here are some helpful pictures that will also help you determine whether you may be suffering from hormonal acne...



 


              


**Always consult with a doctor when dealing with a medical condition, such as acne.  The information contained in this blog is not meant to treat, prevent, or cure any medical condition.  The tips provided are solely based on my own personal experiences suffering from acne and hormonal acne.

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Facebook Is Revolutionizing The Search For An Organ Donor, But Is It Fair?


This week The New Yorker ran a fascinating article called, "To Donate Your Kidney, Click Here".  More and more people are turning to Facebook to try and find living organ donors.  And while many have found tremendous success using this strategy, the article highlights the serious ethical concerns that now face the medical and public health communities in light of this trend.

Concerns About Disparities

The Advocates

While data show that Facebook is the most popular social networking site among online adults, we do not know how social media advocacy skills translate across demographic variables.  In The New Yorker article, Dr. Dan O'Connor of Johns Hopkins University asks "“Whenever you’re using platforms like Facebook, the question is, what kind of person, what demographic profile has the time and energy and communication skills to make this work?” [bolding added]

The Donors

Dr. Michael Shapiro (who chooses not to perform kidney transplants on donor-recipient pairs who met through online advertising) said, “It’s not hard to imagine that if you’re attractive and young and appealing, it’s easier to get people to donate to you than if you’re short or ugly or have a hunchback. And that’s not the way we want the system to work." [bolding added]

While there is limited research regarding Facebook donor-recipient matching, research out of Loyola University offers support for Dr. Shapiro's concerns.  After examining Facebook pages seeking kidney donation, the researchers found that certain types of pages (i.e., white patients and those with more posts) were more likely to have people come forward and get tested to be a possible donor.

Leveling The Playing Field

As with any health or access disparity, public health needs to innovate solutions to narrow the gap.  The New Yorker article discussed Dr. Andrew Cameron (a transplant surgeon at Johns Hopkins) who is working on one possible solution.  He is developing a smartphone application which may level the playing field for patients/families for which social media tools and advocacy resources are less intuitive or accessible.  The app would offer a “template” for those in need of organs to tell their story, and would provide a system for those users to connect directly with transplant centers and social media resources.

What Do You Think?

  • Does donor matching on Facebook provide an advantage to certain demographic groups?
  • What can we do to level the playing field for those patients/families with (1) limited access to social media tools or advocacy skills? (2) stories that may be "less attractive" to the public?
  • Are you surprised that some surgeons (e.g., Dr. Michael Shapiro profiled in The New Yorker) choose not to operate on pairs who meet through online advertising?

Bonus Read: This is not the first time that Facebook has been part of the organ donation dialogue.  Last May I wrote about Facebook's "share life" tool, which allows users to share their organ donation status on their timeline.  Since then, research has shown that the tool is effective in increasing donor numbers.
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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.

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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.
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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.
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Panera Bread CEO Eats On $4.50 Per Day: Good for Public Health or Just Good for PR?

The issues of food insecurity and the Supplemental Nutrition Assistance Program (SNAP- formerly known as Food Stamps) are quite timely.  September is Hunger Action Month and the House has just passed a bill that will cut $39 Billion from SNAP.  Acknowledging this, I wanted to talk about the CEO of Panera Bread.  Over the past week, Ron Shaich has undertaken a well-publicized Feeding America SNAP Challenge.  His goal was to shop for meals with the daily average per person ($4.50) benefit provided by SNAP in order to get a sense of the challenges faced by those struggling to put food on the table.  Feeding America encourages those participating in the challenge to share their experiences in order to raise awareness of “this critical nutrition program”.  Ron wrote about his experience on his LinkedIn Blog from September 9-20, 2013.

I thought his initial posts did a good job of outlining realistic goals:

  • (1) To help bring awareness to the issue [I’ll take it- even though all Pop Health readers know I hate the term “awareness”] and 
  • (2) Spark deeper conversations about food insecurity and possible solutions.  

Ron also highlighted an important caveat: His experiences from the challenge week are not meant to provide an authentic representation of food insecurity in America.  He understands that the issue is much more complex.  Over the course of the week, he discussed how his shopping and eating habits changed during the challenge.  For example, he visited a supermarket known for their low prices.  He also swapped out typical fresh goods like yogurt for “filling” foods like grains.  He documented the mental and physical side effects of his altered diet such as fatigue, irritability and resentment.  Some of his major take-aways from the challenge were:

  • (1) One week is not sufficient to truly understand food insecurity, 
  • (2) Food dominates your thoughts when it is not readily available, 
  • (3) Increased empathy for those who struggle, and 
  • (4) The importance of eliminating judgment and preconceived notions about those who are food insecure and/or require assistance from the SNAP program.

My thoughts:

  • The Challenge and blog posts did not reveal anything unexpected; however it is worth it to read his posts just for the reader comments.  I am always impressed with how social media can solicit engagement and dialogue about public health topics.  While some readers were very supportive and applauded Ron for his efforts, others were quite critical- highlighting important limitations of his undertaking.  For example, its simplicity.  Readers pointed out that it is not just about food insecurity.  It is the stress of having your home, food, job, and transportation be unstable all at once.  They also pointed out how easy it was for him to jump in his car to visit a less expensive grocery store.  Families that are limited by transportation and geography do not have that option.   
  • For me, this simplicity was highlighted in the juxtaposition of Ron’s SNAP challenge with many of the photographs that he used to accompany his blog posts.  For example, on day #4 we see Ron cooking his inexpensive dinner in a gorgeous kitchen.  On days #5,6,7 we see Ron eating in his beautifully outfitted office and building kitchen.  
  • The readers/commenters did a great job (better than Ron in my opinion) of highlighting community and society-level contributors to food insecurity.  They discussed implications of current minimum wage pay.  They discussed families stuck “in the middle”- not qualifying for SNAP but not making enough money for their families to eat.  They discussed the underemployed- those working multiple low-paying part-time jobs without benefits.  They discussed how the culture of our country has changed- citing examples from past generations when employees were highly valued.  They discussed the high cost of food- and the lack of healthy options for those living on a strict budget.  I was especially moved by the first comment on his day #5 post.  The comment comes from a former Panera worker who left after 4 years due to low wages that rendered her unable to support herself.  She writes that “many employees at the stores I worked at are food insecure, as well as myself.”  While she acknowledged Panera’s philanthropic efforts, she asked Ron “why not look in your very own kitchens for people to help as well?”   
  • I also took note of Ron’s communication channel selection.  He used his existing blog on LinkedIn.  I’m hoping to track down reliable data on the demographics of LinkedIn users (e.g., education and income levels) so that I have a better sense of his targeted audience.  According to Pew Internet research, only 20% of online adults use LinkedIn (as of August 2012).  Therefore, it just made me wonder: who might be left out of the conversation due to the blog’s location?  [*If any readers can share a reliable data source on demographics of LinkedIn users, that would be great!]
  • Since Ron’s goal is to spark deeper conversations about food insecurity and solutions, only time will tell if his company's actions will change as a result of this SNAP challenge.  Hopefully they will build upon existing efforts (like Panera Cares) to help address food insecurity at the community, society, and policy levels.

What do you think?
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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.



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Our Meaningful Use Stage 2 Certification Strategy


Two weeks ago, ONC created a very helpful Certification Guide for EHR technology developers 

Many people in the industry have told me that the most challenging scripts are the demonstration of CCDA generation/display/Direct transmission (45 CFR §170.314(b)(1) and 45 CFR §170.314(b)(2)), the Clinical Quality Measures (45 CFR §170.314©(1)-(3)), and Patient View/Download/Transmit (45 CFR §170.314(e)(1)).

Although some stakeholders have suggested that these criteria are too aspirational, using standards that are still maturing, I think it is unlikely that rule making will alter their intent.   I also think it unlikely that the test scripts will be significantly revised to reduce the complexity of certification.

As I wrote recently in my post about What Keeps Me Up at Night, the only way to pass an impossible test is to change the rules.

Our approach has been to leverage the modularity of Meaningful Use Stage 2 to divide up the work among vendors, the State government, and our own developers.

Here's how we're doing it.

The State HIE, MassHIWay, fully implements the Direct protocol including certificate validation - everything required by §170.314(b)(2).   Unfortunately, modular certification does not enable the splitting of a script, so in order to use the MassHIWay for all of §170.314(b), we also need to demonstrate its ability to generate and display a CCDA.   Luckily, the MassHIWay received an innovation grant to create the Surrogate EHR Environment (SEE) application for LTAC/SNF/stakeholders without an EHR.   This application can generate and display CCDAs.   We'll leverage the MassHIWay capabilities and demonstrate its Direct functionality as part of the BIDMC self-certification efforts.   Then, we'll help all the other users in the Commonwealth by getting it certified as a §170.314(b) compliant module so that anyone in Massachusetts can include it in their attestation.

The Clinical Quality Measures require demonstration of QRDA Category I (Patient-level) and
QRDA Category III (Aggregate-level) capabilities.  They also require stratification by several demographic data elements to support disparities of care reporting.   The test script results in a QRDA that is over a megabyte because 21 test patients with 29 measures are stratified 3 ways.   Rather than apply significant resources to QRDA programming, we chose to outsource our quality reporting to the Massachusetts eHealth Collaborative Quality Data Center (QDC), as described in my earlier blog about our ACO strategy.   The QDC takes CCDAs from each of our EHRs and produces all the reports needed for ACO, Meaningful Use and PQRS reporting.    Last week, MAeHC achieved modular certification for all its CQM reporting.

The Patient View/Download/Transmit (VDT) scripts are tough because the ecosystem of products supporting patient transmit workflows is still very immature.   We are implementing VDT in two ways.   The MassHIWay will connect to a PHR and thus we'll likely include the MassHIWay VDT features in our self certification.   We'll also augment our Automated Blue Button (ABBI) functionality so that a patient can initiate an ABBI transmission instead of relying on a transition of care event, as is now the case.   Our ABBI code is open source from the Direct project.

Thus, by building our core EHR functionality and certifying it supplemented with modular certification of  the state HIE, the Quality Data Center, and Automated Blue Button, we can get to a full "shopping cart" of functionality to support hospital and professional attestation.

It took us half a day to achieve Meaningful Use Stage 1 certification.   We estimate that 3 full days of demonstrations will be required for Meaningful Use Stage 2 certification.

The division of labor described above will make it possible to us to certify all our software in time for early 2014 reporting periods and attestation.
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Ideal Method of obtaining Rid Of Acne-The Different Ideas That you simply Can Adhere to (train articles)



1st, it's important that you simply ought to know the rationale why pimples, maintain appearing with your experience. The Pimples and acne look around the pores and skin on account of surplus humidity or oil content material which is current with your pores and skin. In case you get treatment of one's oily pores and skin or maybe the humidity accumulation with your experience than I'm certain, you'll by no means need to encounter this issue yet again inside your lifestyle. Acne end up into a far more extreme issue, in the event you contact them along with your palms at standard intervals.
If you'd like to understand very best property solutions for acne breakouts than these are generally according to:
1. Try to eat much more quantities of clean veggies and fruits; these may help you a great deal, as these incorporate anti-oxidants that support to dissolve the squander material of one's entire body. As an example orange incorporate citric acid, that is really very good for the pores and skin, apple is made up of all of the multivitamins that assists to take care of the normal oil stability of one's pores and skin.
2. Consume far more quantity of mineral water, specifically the distilled one particular, has really powerful results with your pores and skin, you ought to consume a minimum of two to four liter of water every day, if you need to remove the annoying acne that seem in your pores and skin.

3. In the event you are utilizing the indicates of antibiotic to eliminate acne, then make certain it truly is a great a single and it is approved by medical doctors.
4. Try out to just take much more quantities of nutritional supplements, as your diet program could not consist of the appropriate quantity of natural vitamins, vitamins, minerals and plenty of other issues which might be important for your system progress.
5. Usually do not use a lot of lotions with your encounter, mainly because it can harm the organic great thing about your experience, for remedy of acne and pimples a variety of lotions can be found in the industry, but make certain that you verify out the components from the product prior to utilizing it.
6. Implement a considerably less quantity of make up on your own encounter, cease making use of any sort of solution that could lead to even a bit discomfort with your experience soon after making use of it.
7. Tension and operate load would be the main motives that bring about the prevalence of acnes and pimples try out to chop them off out of your lifestyle, you will find a variety of meditations and exercise routines that you just can perform to as they're the easiest method to do away with acne breakouts.
Acne are brought on by a single cause or even the other, however, if you stick to the above-mentioned suggestions of home remedies for acne compared to the outcomes is going to be witnessed by you in only even a couple of days.
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#NotDeadYet: Slate Sparks An Awesome Online Discussion of Life, Medicine, and Public Health


Last Thursday Slate, a daily web magazine, kicked off a series on life expectancy.  I highly recommend taking the time to read the articles, which cover everything from notable public health advances to improving maternal/child health outcomes.  I was very pleased to see many public health organizations sharing these articles with their followers.



While the content was enough to draw me in, I was particularly intrigued by the online dialogue that was sparked by this series.  Over the past week, my Twitter feed has been filled with colleagues participating in the discussion using the hashtag #NotDeadYet.  In the series' first post, "Why Are You Not Dead Yet?", Laura Helmuth explores why life expectancy has doubled in the past 150 years.  At the end of the post, Laura asked readers to send their #NotDeadYet survival stories to Slate's twitter or email accounts.  A selection of the submitted stories ran today to wrap up the week-long series on life expectancy.

With so many newspapers and blogs (mine included) heavily depending on the comment section to initiate discussion, I was intrigued by the idea of starting an accompanying Twitter hashtag thread.  Impressed by the high participation rate just on my own feed, I reached out to Laura Helmuth to gather more information about her dialogue with readers.  She was very gracious to respond to my questions during what I assume has been a very busy week with the series!    

She shared that Slate received more than 200 emails from people sharing their stories (some of them quite elaborate). They also received about 800 responses on Twitter.  In terms of story content:

  • About a quarter of the emails concerned childbirth- women who would have died giving birth and people who would have died when they were born. 
  • Many of the Twitter messages were also about childbirth, including a lot of men who tweeted that they would be childless widowers right now if it were not for modern medicine. 
  • Slate also heard from a lot of people who survived a burst appendix. Lots of people were saved from nasty infections by antibiotics. And some had gruesome accidents that were patched up in surgery. Lots of people have had heart surgery. Many people credited their anti-depressants for keeping them alive. A surprising number mentioned that they were treated with antivenins for snakebite! 

Laura noted that this hashtag thread was especially heartwarming because "people were taking a moment to share their scariest stories and express gratitude that they’re ALIVE".  She also said that "it’s a great reminder that so many of the people we know would be dead if it weren’t for treatments we sometimes take for granted". A big thank you to Laura for sharing these responses and her reactions!

After putting this post together, I have two messages- one about the content and one about the strategy that Slate used for communicating this story.  
  • (1) It is important to look back and inventory the medical and public health advances that we take for granted.  Last year I wrote about the wonderful Frontline documentary, "The Vaccine War".  When discussing fears of vaccination and the decrease in childhood vaccination rates, the documentary noted that this new generation of parents are too young to know the devastating effects of vaccine-preventable diseases like polio.  One interviewee used a term that I really like- "Community Recollection".  As Community Recollection of these diseases disappears, we can become complacent.  We are seeing the devastating results of this complacency with outbreaks of preventable disease (for example the outbreak of Measles just a few weeks ago in Texas). 
  • (2) We in public health should take note and learn from the strategies that Slate has used to engage readers.  We are always looking for ways to initiate conversation beyond the articles we publish or the classes we teach or the webinars or twitterchats that we facilitate.  A few observations:
    • The hashtag thread allowed them to take the discussion beyond the comment section onto Twitter.  
    • Hashtags are easily searchable, so new participants could quickly be gained that did not originally follow or read the magazine.  
    • The hashtag #NotDeadYet was innovative and "catchy" not boring like #PublicHealthAdvances.  
    • Readers also had an incentive to share their stories, since Slate was selecting the top 50 to wrap up the series.   
I'd love to hear from my readers!
  • Did you read the Slate life expectancy series?  Reactions to share?
  • Have you tried similar strategies to engage readers with the content that you distribute?  Success stories or lessons learned to share?
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Building Unity Farm - Preserving the Harvest


As Fall approaches in New England we're picking apples/fermenting cider, extracting honey, canning jams, preserving vegetables, and finishing our Fall mushroom inoculation.

Here are a few scenes of the harvest - a very busy time of year.

The Unity Farm orchard contains 36 trees - Apples, Cherries, Peaches, Pears, and Plums.   We have 180 high bush blueberry bushes and 150 low bush blueberry bushes.    We have elderberry, raspberry, and pecans.    Here's an overview of the layout.


Last weekend we picked Honeycrisp, McIntosh, and Asian Pear.    We crushed the apples into cider and pasteurized it into quart containers.   Here's what the process looked like in the cider house.



In August we picked blueberries and created Unity Blue jam, a mixture of berries and other natural ingredients from the farm.    We've applied for a license to sell our farm products at farmers markets and other retail locations.   As soon as the license is granted we'll be able to sell Unity Blue - here's what the finished package looks like.



I'll write an entire post about the honey extraction process, which requires a bee suit, a smoker, a hive tool to gently remove the frames containing combs of honey, a tool to uncap the combs, and an extractor to remove the honey from the wax.    We gathered 240 ounces of honey from our 8 hives and we will leave all remaining honey for the bees to use over winter.   Below is the alternative u-pick method, that we've chosen not to use!



Finally, we've prepared 220 shitake, 72 oyster, and 6 lion's mane logs so they are ready to fruit with mushrooms in the Spring.   Here's a view of our laying yard where oyster mushrooms are growing on poplar.   Our shitake and lion's mane logs are kept in the shade house.



We're on the cusp of selling the products of Unity Farm.   By next year, we should have commercial quantities of fruit, vegetables, mushrooms, honey, and fermented cider.   The great thing about life in New England is that each season brings a new adventure and as we finish our harvest, we can dream about the new farm possibilities we'll have in the Spring.

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EMAR Go live


On September 4, BIDMC went live with its innovative web-based, mobile, "Amazon.com shopping cart" inspired electronic medication administration record.

Using a combination of iPads, iPhones, bar code readers, and thin client (HTML, Javascript) cloud hosted software, we have eliminated paper-based medication records on a major medical floor.   As is typical with our user centered design methodology, we'll incorporate improvements as we incrementally implement the software across the enterprise.

Our standard user centered design process includes:
  *Clinicians define requirements in our governance committees
  *Clinicians and developers create products
  *Limited pilots are conducted and feedback gathered.
  *Revisions are made and re-piloted
  *When clinicians judge the product to be mature, pilots are expanded and phased rollout is done.
  *Governance committees meet monthly to review functionality and prioritize enhancements.

The entire process is agile, clinician focused, and continuous

Although BIDMC builds and buys software based on requirements and product maturity, EMAR is a perfect example of when clinicians writing software for clinicians makes great sense.

Nurses created the user interface following of the motif of the Amazon.com shopping cart - you "buy" medications with one click when giving them to a patient, then "check out" to record your "purchases" in the permanent medical record.    All of this happens in real time as bar codes are scanned.   iPhones show each nurse what has been ordered and what has been administered.  iPads at each Omnicell medication cabinet show nurses what work needs to be done.

Here are a few screen shots




Comments from nursing thus far have included "this saves me so much time", "an incredible enhancement", "a major safety gain".   Rarely have I attended a go live debrief in which all the stakeholders expressed such joy and satisfaction.

Clinicians designing software for clinicians, using mobile and thin client cloud hosted approaches, with continuous improvements during enterprise rollouts.   It's a formula that works for our culture.

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Research Notes: Alcohol Brand References in U.S. Pop Music

Today I'm launching a new feature on Pop Health called "Research Notes".  This feature will highlight new peer-reviewed research that integrates public health and pop culture.

Researchers from the Boston University School of Public Health and the Johns Hopkins Bloomberg School of Public Health have recently released a study that examined alcohol references in popular music.  The study is published early online in the journal Substance Use & Misuse:

Alcohol Brand References in U.S. Popular Music, 2009–2011
Michael Siegel, Renee M. Johnson, Keshav Tyagi, Kathryn Power, Mark C. Lohsen, Amanda J. Ayers and David H. Jernigan
(Posted online on August 23, 2013; doi:10.3109/10826084.2013.793716)

The study highlights several interesting findings:
  • Four alcohol brands (Patron tequila, Hennessy cognac, Grey Goose vodka, and Jack Daniel’s whiskey) accounted for more than half of alcohol brand mentions in the songs that mentioned alcohol use in Billboard’s most popular song lists in 2009, 2010 and 2011.
  • Alcohol mentions were most common in urban songs (rap, hip-hop and R&B – 37.7% of songs mentioned alcohol), followed by country (21.8%) and pop (14.9%).
  • Alcohol use was portrayed as overwhelmingly positive, with negative consequences rarely mentioned.
In the study's press release, researchers highlight several practice implications of these findings:
  • “Given the heavy exposure of youth to popular music, these results suggest popular music may serve as a major source of promotion of alcohol use among youth,” said study co-author David Jernigan, PhD. “The findings lay a strong foundation for further research.”
  • “A small number of alcohol brands and beverages appear to make frequent appearances in popular music,” said Michael Siegel, MD, MPH, professor of Community Health Sciences at the Boston University School of Public Health. “If these exposures are found to influence youth drinking behavior, then further public health efforts must be focused on youth exposure to alcohol portrayals in popular music.”
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The September HIT Council meeting



Yesterday, the Massachusetts HIT Council met to review progress on the state HIE.   Here is the presentation we used.

Important highlights include:
*41 organizations are now connected to the state HIE
*We've done nearly 1.5 million transactions
*We've decided how to create a trust fabric with other Health Information Service Providers (HISPs).   We will support authentication by exchanging trust anchors and signing HISP to HISP agreements. We will support authorization through the use of a white list that includes those organizations which have signed our Massachusetts participation agreement
*In late October/early November we will demonstrate Phase 2 of our HIE functionality - a statewide master patient index and consent registry which supports "pull" transactions such as patients arriving at Emergency Departments, enabling us to gather medical information from multiple institutions.

To me, we're near the tipping point of interoperability.   The standards, the ACO imperative to share data, and the motivation of meaningful use Stage 2 have created the perfect storm for providers, payers, and patients to share data.
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Choose The Best Herbal Product To Get Fairer And Pimple Free Skin (Auscause Barrymore)

Pimple also known as acne vulgaris is a skin infection that affects most teenagers at the onset of puberty. The over activity of the sebaceous glands which is influenced by hormonal changes during puberty is the main reason that leads to the outbreak of pimples among teenage boys and girls. The face becomes excessively oily attracting grime and dirt attracting bacteria. Pimples can be of several types namely - blackheads, whiteheads, papules, pustules, nodules, cysts, etc. Apart from over the counter medications there are many herbal products in the market today that will help you get fairer and pimple free skin. In the following section we have discussed some of them.
Herbal Products
1. Vicco Turmeric WSO - This cream contains turmeric powder and is helpful in the treatment of pimples and scars.
2. Kumkumadi Tailum - This oil contains saffron and has been used for years in Ayurveda for the treatment of pimples and scars. It helps to get fairer and pimple free skin
3. Biotique Myristica Spot Correcting Anti-Acne Face Pack - This spot application face pack contains effective herbal ingredients like Haldi, Jaiphal, Pippli, Geru, Multani Mitti, Kikkar and Gaund that helps in reduction of redness and skin inflammation.
4. Bio Wintergreen Spot Correcting Anti-Acne Cream - This anti-acne cream contains the essential oils of wintergreen leaves which contains methyl salicylate and gaultherilen. It has antifungal and antimicrobial properties that are helpful in the treatment of pimples or acne.

5. Biotique Chlorophyll Oil Free Anti Acne Gel - This anti acne gel contains herbal ingredients like seaweed, chlorophyll, sea algae, aloe vera and gum Arabic that tightens pores, helps clear skin blemishes and provides the much needed nourishment for oily skin. This is a great product to get fairer and pimple free skin.
6. Himalaya Herbals Clarina Anti-Acne Face Mask - This anti-acne face mask contains effective natural ingredients like Indian Willow, Barbados Aloe, Turmeric which are effective in controlling pimples.
7. Himalaya Herbals Clarina Anti-Acne Cream - This cream contains effective natural ingredients like Barbados Aloe, Almond, Indian Madder which is a great product to get fairer and pimple free skin.
8. Golden Glow Capsules - Regular intake of these capsules will help you get fairer and pimple free skin. It is an effective blend of natural ingredients like terminalia chebula, rubia cordifolia, exadirecta indica and rosa centifolla. It is completely safe.
9. Vita Medica - A nutritional supplement containing vitamin A (retinyl palmitate plus Betatene) plus zinc, selenium and chromium, burdock, dandelion, oregon grape and yellow dock which controls outbreak of pimples and helps to get fairer and pimple free skin.
Hence we can conclude that the herbal products mentioned above will help us to get fairer and pimple free skin.

Processing ...
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Building Unity Farm - The Cider House Tools


The orchard at Unity Farm has 36 trees, of which 24 are heritage apple varieties.   Since each tree will produce 5 bushels (a bushel is 42 pounds), we'll have 120 bushels (over 5000 pounds of apples per year) when the trees reach maturity.    Of course we'll eat, sauce, jelly and produce various apple products from them, but my favorite way to enjoy fresh apples in the Fall is to make cider.

One bushel yields about 3 gallons of cider, so we could make up to 360 gallons.

Cider can be frozen and kept for a year but even with pasteurization (which changes the flavor), unfrozen cider will not keep more than a few weeks.

The easy answer to preserving cider is to make traditional fermented hard cider.

Here's how we'll do it.

In the orchard, we have a cider house, pictured above.  All our orchard harvesting and honey processing tools are kept clean and dry in that building.  We have a 36 liter cider press and grinder which can produce about 9 gallons of juice per pressing, pictured below



We'll test our apples for flavor, acidity, tannin content, sweetness, and bitterness then choose a combination of apples that will make a balanced cider.  Our hand cranked fruit grinder sites on top of the press and we'll fill the pressing basket with approximately 2 bushels of ground apples.    We'll apply pressure via the hand cranked ratcheting screen and gather the juice a gallon at a time.  I prefer a two stage fermentation with racking of juice from the spent yeast for a clearer final product.   I have two fermenters made from food grade HDPE plastic, which is unbreakable and easy to clean.   I've had good luck in the past with Champagne yeast  and will make a starter culture the night before pressing.   Once inoculating, I'll let fermentation proceed naturally in the 60 degree outdoor temperatures that are typical in late September/early October.  When the initial fermentation is done, I'll siphon the juice from one fermenter to another and let it ferment another week.  

I prefer my ciders to be very dry, so I do not plan on adding any sweetener before bottling.   I will likely make a few bottles of sparkling cider as well, adding a bit of sugar solution then bottling in swing top containers.   After a few months the cider will mellow and carbonate, ready to ring in the new year if all goes well.

Since hard cider has been an American home brew tradition for hundreds of years, the laws regulating production and distribution are simpler than wine.   In a few years, I hope invite friends and colleagues to bring their growlers to fill with Unity Farm cider, hand made with our cider house tools.
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What Can “Chronic Resilience” Teach Public Health Practitioners? An Interview With Author Danea Horn


Last month I had the pleasure of receiving an advanced review copy of "Chronic Resilience: 10 Sanity-Saving Strategies for Women Coping with the Stress of Illness".  As I read through the book, I made note of many issues that are relevant to public health practitioners.  Therefore, it is a pleasure to have Danea Horn expand her comments on these topics for Pop Health readers. 

If you would like to connect with Danea, you can visit her website or twitter.

Leah:  In public health, we talk a lot about how our society’s “culture” can promote or harm health.  In several places in your book, you talk about the connection between our societal values and our health.  For example:

Page 33: “Part of the reason we try to be all things to all people is our culture.  Have you ever sat through a business meeting while someone is sniffling and sneezing and exposing everyone else to their cold?  In that moment they are valuing achievement, money, or appearances above their health and the health of everyone else in the room.”

How can we expand your strategies beyond the individual level?  How can we identify and live our health values at the neighborhood, community, and organization levels?

Danea:  It only takes one person to start a conversation that can become the catalyst for big changes. Start talking to people at your work and in your community to get a feel for what is valued currently. The policies (written and unwritten) in our offices and items at our potlucks will say a lot about what we collectively value. If you find inconsistency or confusion in your conversations, open up a dialogue with the leaders in your organization or community to discuss what you would like to collectively choose to value. From here you can brainstorm together ways to influence change. They can be small changes like creating a healthy living block party where people share nourishing dishes and swap good-for-you recipes or larger changes like paid sick leave (which is not mandatory in every state…yet). Never be afraid to speak up. A big theme in Chronic Resilience is controlling what you can control and talking is in your control. 

Leah:  In Chapter #6, you write “It is up to you to decide how public to make your health.”  You and several of the women you interviewed for your book have blogs that document your health journey in a very public way.  Public health researchers Ressler et al (2012) have identified many benefits of patient blogging (e.g., patients report a decrease in feelings of isolation).

What benefits have you experienced as a result of writing about your health?  What challenges have you encountered during the process of sharing your story publicly?

Danea:  Writing helps me process what is going on from a different perspective. I am all about learning from our challenges, so each post I write is a search for a lesson or message that my diagnosis is pointing me toward. I can feel frustrated about the progression of my disease and start out writing a rant, but I find that I naturally end up with a message about letting go of my ideals or acceptance. Reframing my health in this way has been very empowering.

I haven’t encountered many challenges by being public with my health journey. Commenters have been very supportive. That said, I am discerning about what I choose to share and do keep some things private. Challenges I know other people have faced, and someone who blogs publicly about their health should be prepared for, are people sharing remedies, treatment recommendations, cure-all solutions and pleas to have faith in a deity they may or may not believe in. While these all come from a caring place they may feel intrusive. Also, you may want to give a heads-up to your close family and friends before you post anything particularly revealing, emotionally or otherwise, that you haven’t shared with them in private first.

There are a number of ways to benefit from writing about your health. Doing it publicly on a blog can create a sense of support and community, but if that feels too invasive, you can join support forums anonymously, create a private blog or journal pen and paper old school style.

Leah:  In Chapter #7 (“Empower Yourself With Research”), I was thrilled to see your emphasis on helping patients evaluate the validity and safety of medical information found on the Internet.  This is a huge challenge in public health!  Our evidence-based messages and guidelines often compete online with anecdotal evidence and unscientific studies.

Why did you decide to dedicate a portion of your book to this discussion?  Why is it so important for patients to discuss what they find online with their medical team?

Danea:  Before I became discerning about what I read online about my diagnosis, I was completely stressed. I read way too much from too many random sources to properly sort out what I should believe. I also noticed that I was searching for how I was going to become sicker (the side effects, complications, and progression of my illness) instead of searching for how I could support my heath. Fortunately, I realized most of my stress was coming from worry created by endless Internet searching, and I decided to take a different approach.

I found a few sources from trusted physicians and nutritionists to study and implement. I decided to stay focused on my personal symptoms, medications and prognosis instead of what other people I didn't even personally know had experienced. I also started a more open dialogue with my doctors about the diet I wanted to try and some of the studies I had read. When we research and experiment with our health without informing our doctors, we may have conflicting approaches which can create drug interactions or other harmful complications. Doctors are there to support us. If you are uncomfortable talking with yours, it’s time to find one that you trust enough to be completely open and honest with. We should all have a doctor who will work with us to find treatment solutions we feel comfortable with.

Leah:  A big thank-you to Danea for making the time for Pop Health!  "Chronic Resilience" is a great read for those with a personal and/or professional connection to chronic illness.  For public health clinicians, practitioners, and researchers who work in the chronic illness arena:  I think you will get a unique first-hand view into (1) the mental, physical, and emotional challenges that affect this population, (2) the incredible resilience that those with chronic illness show on a day-to-day basis (what can we learn from them??), and (3) specific strategies that can be employed to support patients with chronic illness.  As Danea and I discuss above, these strategies have the potential to be expanded from the individual level to offer support to entire communities.
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The August HIT Standards Committee


On August 22nd, the HIT Standards Committee held it's 50th meeting.   We began this milestone meeting by thinking Farzad Mostashari for his national service via a formal proclamation highlighting his accomplishments.  Richly deserved.

Liz Johnson and Carol Bean then presented an Implementation Workgroup update, describing the findings from the Implementation/Usability hearing on July 23rd and presenting test scenarios which will hopefully replace/augment the existing certification scripts.  

They key idea is that scenarios would mirror real clinical workflow from registration to evaluation to transition of care, using the same data and building upon each incremental data entry step.   Such an approach not only reduces the burden of certification but also ensures the EHR is more than disconnected functions built to satisfy disconnect certification criteria.   In effect, scenarios demonstrate the usability of integrated functionality.   I'm also hoping that these scenarios remove some of the certification demonstrations are not part of attestation workflow.    In my view, certification should only include the minimum functionality clinicians need to support attestation and nothing more.   As I posted in my blog yesterday, creating too many regulatory demands can stifle innovation.

Next, Dixie Baker presented an NwHIN Power Team Update finalizing the recommendations for future transport standards.   She reviewed the work of Blue Button Plus, HL7's Fast Healthcare Interoperability Resources (FHIR), and the S&I Framework's RESTful Health Exchange (RHEx) to identify industry trends and emerging standards.   The team concluded that combination of RESTful transport supported by a specific implementation guide and supplemented with OAuth2/OpenID for authentication holds great promise as a simpler to implement approach than currently required in Meaningful Use.   The team also concluded that FHIR has many appealing simplifications as a content standard.      The Standards Committee recommended pilots and once we have real world experience with the combination of RHEx/OAuth2/OpenID/FHIR we should seriously consider their incorporating into future stages of Meaningful Use.

Finally, Lauren Thompson and Jodi Daniel provided an ONC update, highlighting work to accelerate HIE, patient/family engagement, and safety.

At our September meeting we'll present initial recommendations for image exchange and early thinking about how to represent advance directives in EHRs.

Making progress.
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What Keeps Me Up at Night - Fall 2013


As Summer draws to a close, I have returned to my usual blogging schedule!

Now that Labor Day has come and gone,  I've thought about the months ahead and the major challenges I'll face.

1.  Mergers and Acquisitions

Healthcare in the US is not a system of care, it's a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers.    As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create "systemness" through mergers, acquisitions, and affiliations.   The workflow to support systemness may require different IT approaches than we've used in the past.   We've been successful  to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via  "magic button" viewing and state HIE summary exchange.   Interfacing is great for many purposes.   Integration is better for others, such as enterprise appointment scheduling and care management.   Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2.  Regulatory uncertainty

Will ICD10 proceed on the October 1, 2014 timeline?  All indications in Washington are that deadlines will not be changed.    Yet, I'm concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation.    Will all aspects of the new HIPAA Omnibus rule be enforced including the "self pay" provision which restricts information flow to payers?  Hospitals nationwide are not sure how to comply with the new requirements.   Will Meaningful Use Stage 2 proceed on the current aggressive timeline?  Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1.   With Farzad Mostashari's departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3.  Meaningful Use Stage 2 challenges

Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine.   One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems.   I have 25 developers and a part time analyst available for the task.   I've read every script and there are numerous areas in certification which go beyond the functionality needed for attestation.    Many EHR vendors have described their certification burden to me.    I am hopeful that ONC re-examines the certification process and does two things - removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.  

4.  Maintaining agility in a resource constrained world

At the same time we have ICD10 (a multi-million dollar burden), Meaningful Use Stage 2 (a multi-million dollar burden), the Affordable Care Act (a multi-million dollar burden), the HIPAA Omnibus Rule (a multi-million dollar burden), and increasing compliance oversight (a multi-million dollar burden), reimbursement is declining, sequestration is squeezing budgets, and fee for service medicine is transitioning to risk based contracts.    The ability of provider organizations to maintain operations while implementing all the new regulatory requirements in parallel is straining healthcare operations to their limits.   Safety, quality, and efficiency innovations are no longer possible because regulatory requirements  have consumed all available resources.

5.  Leading in real time

My organizations maintain hundreds of applications and thousands of devices with 99.9% reliability.    Rather than praise us for our diligence, the average user in 2013 wants to now why we are not meeting their needs .1% of the time.  When I do not respond to a request in 5 minutes or less, I'm asked if something is wrong.   Leadership in the era of Twitter is expected to be all seeing, all knowing, and omnipresent.   Strategic thinking, planning, and consensus building is challenging in a real time world that expects instant gratification.

I do not mean to sound pessimistic in any way.   All of these challenges can be conquered.   For nearly 20 years, I've led an IT organization that has continuously delivered miracles with 1.9% of the operating budget.   I am ready for the challenges ahead but wonder if mergers/acquisitions, regulatory uncertainty, MU2 certification challenges, resource constraints, and real time demands will create a set of constraints that are impossible to optimize.    Given that my role is to understand all the constraints and find a path forward, it's the Kobayashi Maru scenario that keeps me awake at night .   As Captain Kirk figured out, if the rules of the game make it impossible to win, the only answer is to change the game.    I remain the eternal optimist and am convinced that if we all work as hard as we can, the rules of the game will be changed so that we can succeed.
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