Building Unity Farm - A Day in June

And what is so rare as a day in June?
   Then, if ever, come perfect days;
Then Heaven tries the earth if it be in tune,
   And over it softly her warm ear lays
JAMES RUSSELL LOWELL

Unity Farm is at the peak of growth now, fueled by warm days, cool nights, and Spring rains.

The Bluebird Meadow, pictured above, is filled with tall grasses and wildflowers.   The three bluebird nest boxes I built are filled with growing chicks.

The Orchard, planted just a few weeks ago, is blooming and filled with its first growth of orchard grass, timothy hay, and meadow mix.

Our 8 bee hives are filling with honey, a mixture of pollen/nectar gathered from the orchard, viburnum, and wildflowers.

Adult rabbits are running thoughout the forest and their babies are hiding in our Cotoneaster brambles

We have an active fox den on the property, midway up the drumlin in the deepest part of our forest, in well drained soil, about 100 feet from our upper wetland.   My guess is that it was an old groundhog den, since the first three feet of the main entrance were recently enlarged and dug into a tall oval shape that enables the fox to bolt out at a full gallop.    Every night when I run our Great Pyrenees through the forest they want to leave the Woodland Path  (Unity Farm has 4 paths - Woodland, Orchard, Marsh, and the Old Cart path) to explore the den.   The alluring scent of fox urine is irresistible .   The one downside to having an active fox den on the property is that one of our Guinea fowl disappeared on Tuesday night.   I believe she was laying an egg in the forest (Guineas are terrible parents) and she was grabbed by a fox before she could fly away.   I found a broken egg, a path of feathers, and no Guinea.    All the Guineas come home to roost at dusk, but on Tuesday night, only 17 of our 18 Guineas returned.

The Unity woodland is covered with ferns of all kinds - cinnamon, hay scented, and sensitive ferns.   I used my scythe to recut the trails through the sea of green underbrush.   I've also had the seasonal joy of removing poison ivy from the trails by pulling it out at the roots.

The new alpaca had their first vet visit this week and we've updated their rabies and CDT (clostridium perfringens types C and D and tetanus) vaccinations.   We checked their ears, eyes, and teeth.   All were perfect.    Since they lived with goats, we checked them for parasitic infections by gathering fecal samples.   Sometimes people wonder how I've learned farming skills.   How do you master alpaca rectal exams?  Just do it!

The most amusing part of the vet visit was checking each new alpaca for the RFID chip implants that are used to positively identify them if a fence is breached and they wander off.    The vet scanned Tahoe, our young male gelding alpaca and could not find his chip.   Just to check the equipment, the vet successfully scanned me, since she had read about my experience as one of the first humans to have implanted RFID identity and medical records technology.

The weekend ahead will be filled with mushroom log inoculation,  adding woodchips to trails, and clearing some of the fallen poplar on the Orchard trail.    There's nothing like a Spring weekend of farm chores to refresh the body, mind and soul.

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Let's Give Paris Jackson Some Privacy and Revisit Safe Reporting on Suicide (and Attempts)!

I always cringe when the announcement of a celebrity suicide or suicide attempt comes through my news feed.  First and foremost, because it is incredibly sad to learn that anyone is suffering enough to consider suicide.  Second, because the news coverage that will follow is often invasive and downright dangerous to the rest of us.  The way the media covers suicide can influence behavior negatively by contributing to contagion or positively by encouraging help-seeking.  I have often written on this topic for Pop Health and even as an op-ed for the Philadelphia Inquirer.  However, the message is so important that it bears repeating.

According to multiple news outlets, Paris Jackson (daughter of the late Michael Jackson) was hospitalized this morning after a suicide attempt.  The story was apparently confirmed by her biological mother Debbie Rowe- Paris was hospitalized with cuts on her wrists.  Now I was already concerned that a 15 year old girl was having these personal, medical details released to the media.  Then I saw the coverage on TMZ and just got plain angry.  I won't link to it here because (1) the irresponsible coverage could be dangerous to readers and (2) I refuse to drive traffic to their site.

As a journalist (or public health communication professional) working on this story, your first stop should be Recommendations for Reporting on Suicide.  Although the guide focuses on suicide, the recommendations are highly relevant for attempt stories as well. The recommendations were developed by leading experts in suicide prevention and in collaboration with several international suicide prevention and public health organizations, schools of journalism, media organizations and key journalists as well as Internet safety experts. The recommendations are based on more than 50 international studies on suicide contagion.  Based on their recommendations, here are some of my concerns with the Paris Jackson articles:

• Sensational headlines:  E.g., "Paris Jackson Attempts Suicide, Rushed to Hospital" (US Weekly)
• Oversimplification:  E.g., "A source close to the family tells Entertainment Tonight exclusively that the reason Paris attempted suicide is because she wasn't allowed to go to a Marilyn Manson concert".
• Including photos of the method of death (or in this case attempt):  TMZ has published multiple pictures of Paris (some undated) that zoom in on her wrists to identify possible cutting scars.  This is bad for several reasons:
• 1- Without any confirmation, the writers are suggesting that Paris has a history of suicide attempts.
• 2- The writers are suggesting that anyone who cuts their body is attempting suicide when in fact, some self harm behavior is non-suicidal.  A good resource for definitions of various forms of self-directed violence comes from the Centers for Disease Control and Prevention (CDC).  There can be self harm behavior (like cutting) without the presence (whether implicit or explicit) of suicidal intent.  

A lot can be learned in public health by monitoring this media coverage, highlighting mistakes, and reinforcing safe messaging.  The Paris Jackson articles should:

• Inform without sensationalizing
• Provide valuable education to readers (including suicide warning signs, ways to help a friend/family member, and resources like the National Suicide Prevention Lifeline)
• Seek advice from suicide prevention experts before reporting on data or making assumptions about Paris' intentions or medical history
• Be hopeful! Emphasize that mental illness is treatable and many local and national resources exist

Resources:

1.  Associated Press (New!) Stylebook Entry on Mental Illness
2.  Recommendations for Reporting on Suicide

3.  The National Suicide Prevention Lifeline 1-800-273-TALK (8255)

What Do You Think?

• What was your reaction to the media coverage of Paris Jackson's suicide attempt?
• What other resources would you add to my list to support safe media reporting on suicide and attempts?

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Presenting the Security Plan to the Board

Today I presented our multi-year information security plan to the BIDMC Board Committee on Compliance, Audit and Risk.  

Here is the presentation I used.

Following our February external review of security policies and technologies, we developed a planning process, and a complete multi-year plan with timelines, budgets, and staffing requirements.

The plan contains 14 work streams, each of which has several components.   Here's a sample work stream planning document illustrating the goals, metrics, timing, and costs.

They key point I emphasized to the Board is that this security work is not just to satisfy federal and state regulatory requirements.   There are many tangible benefits of the work ahead including adoption of the NIST 800 framework, which formalizes our approach to risk management and priority setting.    We'll tightly manage user roles (access by job role rather than person),  devices allowed on the network, and remote access methods/rights.

All of this improvement does have a capital implementation cost and an operating maintenance cost, since we will be adding several new applications that require 24x7 support.

Although I did provide a detailed, phased project plan for each of the work streams, there is one planning task to do.  

Each of the components in the 14 work streams has an associated priority, risk, and cost.   Management at BIDMC will select a collection of projects to begin immediately which we believe will offer the greatest benefit, can be widely adopted by the organization and are affordable.   We will refine our FTE, capital budget, and operating budget requests once we constrain the scope of work to that collection of projects.

We'll ask the original external security reviewers, our multi-stakeholder working group, and the management committee on audit, risk and compliance to offer feedback on the go forward scope.

In many ways, BIDMC tries to be a leader in application and infrastructure innovation.   In the world of security, since risks evolve so rapidly and the future is hard to predict, we have to set scope carefully so that we're good enough - neither over or under implementing appropriate controls,  acquiring the right amount of technology, and hiring the right spectrum of staff.

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Massachusetts HIE Update

Yesterday, the HIT Council met to review Massachusetts Healthcare IT progress.

Here is the presentation we used.

The meeting began with a presentation from Holyoke Medical Center, describing an ideal subnetwork - a local HIE that meets the needs of local stakeholders while also connecting to the state HIE, enabling any authorized stakeholder in the Commonwealth to send and receive summaries to/from the Holyoke medical community.

Next, I gave an update on BIDMC's progress.   BIDMC is now live sending immunization transactions to the Department of Public Health over the state HIE.  We're also sending 4000 transactions per day to the quality data center at the Massachusetts eHealth Collaborative.  Today we go live with Network Health for transition of care exchange and in the upcoming weeks we'll go live with Partners healthcare for encounter summary exchange.

Next, we reviewed HISP to HISP trust fabric approaches and consent issues.   For HISP to HISP exchange we agreed that we need both authentication (who you are) and authorization (what you can do).   Although certificate trust bundles like those offered from DirectTrust.org can address federated authentication issues, we'll likely implement authorization within the state HIE as we move from "push" models to "pull" which enable authorized users to retrieve records on demand.  

Massachusetts is an opt-in consent state and we reviewed recommendations for consent processes and language.   Our current recommendation is for HIE participants to obtain opt in consent during the general consent for care signing process and to specifically enumerate the state HIE as a means to share data in the notice of privacy practices.

We reviewed the FY14 plans for the Massachusetts eHealth Institute, the organizations in Massachusetts that accelerates EHR adoption and assists with connecting the "last mile" of provider practices to the HIE.

Finally we reviewed our plans for creating a statewide master patient index, record locator service, and the supporting web services to enable query/response ("pull") health information exchange.  We're on track for an early 2014 go live and all funding is in place.

A great meeting.

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Building Unity Farm - Adopting Alpaca

Memorial Day weekend was a busy time at Unity Farm - spending time with our newly adopted alpaca, doing woodland/forestry management, and inoculating mushroom logs.

How did we adopt new alpaca?

In an unusual chain of events,  a leading alpaca breeder in Maine was the former editor of a healthcare IT magazine and knows me well.   When she heard about a family in Massachusetts trying to place their three alpaca, she recommended Kathy and me as caring adoptive parents.

We gently loaded the alpaca into a transport vehicle and drove them 20 miles from their current home to their new home at Unity Farm.

Since we're introducing new animals to an existing herd, we decided to quarantine them for 4 weeks in our pasture, away from the other alpaca.    

We drove the vehicle into our pasture, closed the gate, and let the alpaca step out on their own.   The picture above shows our newly adopted alpaca - Juniper (dark brown), an 8 year old female; Mint (white), her 2 year old daughter;  and Tahoe (light brown), an 8 year old gelded male.

They have their own loafing shed, hay supply, minerals, grain bowls, and half an acre of orchard grass to munch.  

Our traveling large animal vet will visit them on June 5.  We'll update all their inoculations, do fecal samples for parasites, and begin injections of ivermectin as a preventive treatment for meningeal worm.

Since we had a 3 day weekend, we also aggressively worked on woodland management.   Now that the orchard has opened up the lower 5 acres of the property, I began hauling fallen trees to the woodcutting area and wood chip grinding area.

Saturday was devoted to clearing an old hickory tree that blew down in hurricane Sandy.  Hickory is the finest firewood available - easy to split, yields high heat, and burns cleanly.     I added half a cord of split hickory to our 5 cords of firewood storage.

Sunday was devoted to ash.  Over the past few years a virus killed many old ash trees and the emerald ash borer caused dieback of ash trees in New England.   Some of those trees have fallen and some are still standing, likely to fall in the next big storm.  I began the process of clearing ash and moving it to the woodcutting area for splitting.  Ash does not require aging and can be burned immediately.   We lit a roaring fire of freshly cut ash wood on Sunday night since the temperatures on the farm dropped into the 30's.

Monday was devoted to poplar.   Many of the poplars on the farm are 65 feet tall and are approaching an age when they are likely to fall in a storm.   Poplar is poor firewood and we generally chip it for use on our trails.    On Monday, I was spreading mulch on the Orchard trail, a winding path between the orchard and our stream.   I stopped for a moment to check email and received an important budget to review.   I walked to the house to view the spreadsheet on a larger screen.   While sitting at my computer, I heard a loud explosion from the lower portion of the property.   Everyone on the farm ran to discover the source of the disturbance.  What we saw made us turn pale.   A 5 ton poplar had fallen on the exact spot I was standing while spreading mulch.   It crushed a portion of the orchard fence and ripped down the gate, 50 feet away.    Can an email save your life?  On Memorial Day, an email saved mine.    It's hard to imagine an obituary that reads "John was standing in the forest when a 10,000 pound poplar spontaneously fell on top of him."    

My wife gave me a large chainsaw for our 28th anniversary last year (the traditional gift), so we had the tools necessary to carefully cut up the 18 inch diameter trunk into 200 pound chunks which we carried to our grinding area.   We temporarily stabilized the fence (two posts were broken and one crossbeam was smashed.    At the moment, the orchard is still deer proof while we await permanent repair.

Finally,  Kathy and I finished our first 110 Shitake mushroom logs - 5000 holes, 30 pounds of mushroom spawn, and 10 pounds of cheese wax to seal the holes.     We can process about 300 pounds of oak per hour, which we did in the late afternoon on Saturday, Sunday, and Monday.     Now that the first 11 oak stacks are completed, each with a different sub-species of Shitake, we'll work on expanding the size of the stacks so that by the end  of June we'll have completed 220 logs - a total of 15,000 pounds of wood.

Luckily, next weekend we'll be moving our daughter into her own apartment at Tufts University.   After our farm workouts, hauling furniture should be easy!

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Clinical IT Governance Update

Yesterday I led the Clinical IT Governance meeting at BIDMC and I thought it would be interesting for my readers to get an inside look of the kind of topics we're discussing and how we're implementing our most challenging projects.

1.  Joint Commission debrief
Last week the Joint Commission visited BIDMC and the experience was very positive.  When there are process variations and potential shortcomings identified by the Joint Commission, IT solutions are often suggested.   In this particular visit, there were a few small software changes made during the visit to better support National Patient Safety goals such  as ensuring all care team members know the preferred oral and written language preferences of each patient.   We made modifications to ensure all our sites of care - ED, inpatient, outpatient, OR, and ICU gather this information consistently and display it routinely.   That was the only issue involving IT in this Joint Commission visit.

One of the great challenges of IT governance is maintaining focus on the annual operating plan and avoiding the distraction of the day.   Audits, visiting committees, and even Joint Commission visits have the potential of creating attention deficits which derail IT staff from long term must do's.    I'm grateful that Joint Commission preparation has become such an integrated part of our standard work that no projects were derailed.

2.  Enterprise and Community interoperability
I'm often asked when interoperability will become a standard practice in communities.   In many Massachusetts institutions, data exchange is already happening and the state HIE is processing over a million transactions a month.   However, there are still gaps in offering hospital-based clinicians access to the EHRs of private practice referring physicians.   I outlined the work we're doing this Summer to ensure that opt-in consent to disclose is captured at referring clinician practices as this will enable us to complete the electronic linkage which provides 24x7x365 on demand data sharing.

3.  Annual Operating Plan update
IT has 5 goals in 2013 and I reviewed our progress on all of them
Meaningful Use Stage 2 - we have achieved all MU2 hospital requirements except Electronic Medication Administration Records/Bedside Medication Verification.   Our new EMAR/BMV application goes live in July and we are on track to have 10% of all medication orders processed through it for the October-December Meaningful Use reporting period.

ICD10 - our greatest challenges are clinical documentation improvement such that enough information is available to justify highly detailed ICD10 codes and outpatient coding strategies so that we do not need paper-based superbills hundreds of pages long for every clinic.   We're working with 2 established companies and one start up to create novel computer assisted coding workflows and real time documentation improvement, linking the act of documenting to the requirements for accurate billing in a single workflow.

Laboratory Information System - we go live with the pathology module in our new Laboratory Information System on August 2.  Integrated testing is going well.

ACO support - we've worked hard to generate all the data necessary for our ACO to produce the quality and financial performance reports required by CMS.   We finished our first year as an ACO with a positive margin.  

Compliance/Security - I presented the project plans for 14 work streams of security enhancements suggested by our recent security audit.   Improvements include network access control, security information and event management applications, and a comprehensive NIST 800 ongoing risk management program.

4.  Conversation Ready Project - As part of  the Joint Commission visit, we showed the reviewers screenshots for a new end of life preference documentation application we're building.   Our feeling is that structured data and metadata around end of life planning is not sufficient.   We need documents which reflect a deep conversation about preferences, so that it what we are creating.   Documents may be handwritten, faxed, typed, or natively electronic, so we need to support multiple document capture workflows.

5.  Patient and Family Engagement in ICUs Grant - We collaborating with a major private foundation to think about patient and family engagement in ICUs.   The Clinical IT Governance committee needed to understand the level of work and its alignment with our strategic plan, meaningful use, and compliance requirements.    I always discuss grant opportunities  with governance committees, because sometimes grants are not well aligned with existing work and become a costly distraction.    The committee asked many good questions about this grant opportunity and we're now poised to refine the workplan with the foundation leaders.

A very productive meeting.

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Use Blood Cleansing Herbal Products To Cure Pimple And Acne Effectively (Lucas Naruka)

How to get rid of acne and pimples naturally and get a charming and glowing skin? This is a very common question asked by women and men who are beauty conscious throughout the world. People are looking for blood cleanser herbal products to cure pimple and acne nowadays. According to studies, natural solutions are proven to be effective to treat pimple and other skin problems. Let's find some of the recommended solutions to treat pimples naturally and safely. Using witch hazel and clay can cure acne problems effectively. Clay face mask can help you in clearing impurities from the surface of your skin.

Besides removing oil from the surface of your skin, clay face mask eliminates impurities as well, it is a perfect choice if you are looking for herbal remedies. Clay face mask includes minerals that boost the tone of your natural skin. In order to get the desired result, people experiencing pimple problems are recommended to use clay along with witch hazel extract. Witch hazel is known for its good astringent characteristics. This feature helps in getting quick relief from small cuts and wounds on the surface of skin. Witch hazel and clay are the best blood cleanser herbal products to cure pimple and acne.

We often see development of bacteria in pimple pus. In order to eliminate the risk of growth of bacteria, you should apply anti-bacterial gel or lotion to your face. According to research, combination of vinegar and honey is very effective in reducing the growth of bacteria. Along with reducing the growth of bacteria, this natural cure is also effective in reducing inflammation or swelling. So these are also one of the best blood cleanser herbal products to cure pimple and acne. Consuming plenty of water is another well recommended natural way of improving skin tone. It washes toxins out of your body and makes your skin glow. Besides physical reason, psychological reason also plays a vital role in having a good, glowing skin. To reduce skin problems, it is also recommended to reduce the health disorders such as depression and stress.

There are many cures available on internet to reduce the problems related to stress nowadays. Performing yoga is one of the best natural ways to reduce or control troubles related to stress. It minimizes stress and maintains balance in hormones without causing any type of side effect. Healthy diet schedule also plays a major role in getting good skin. It is recommended to follow a healthy diet in order to make your skin look radiant, avoid fried and sugary foods as much as possible. Vegetables, poultry, whole grains and fresh fruits are some of the recommended foot items for a healthy skin.

Have you ever heard about Glisten Plus capsule? This herbal remedy is one of the most recommended products to treat acne and pimples and get a radiant, glowing skin in a natural way. Glisten Plus capsules help in purifying the blood and reduce the appearance of skin infections because of fungi and bacteria. This herbal remedy is an ideal choice for you, if you want to make your skin look healthy, tight and charming. You can easily get this herbal product in market and from online stores these days.

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