Attestation verses Certification for HISPs

Of all the Meaningful Use Stage 2 questions I'm asked by vendors, HISPs, and providers, many involve confusion between certification and attestation.

As I've written about several times, the certification criteria are so extensive, often in unnecessary and confusing ways, that few vendors have been able to get through them.   Certification criteria exceed attestation criteria in many scripts.

I was recently asked about transition of care data exchange using Direct and the need for message delivery notification (MDN).   Micky Tripathi wrote the following excellent analysis, the bottom-line of which is that MDN is a narrow certification criteria, not an attestation requirement.   In the future, I think certification must be simplified to include the bare minimum necessary to support attestation.     Many people on the Standards Committee feel the same way and we'll support whatever polishing strategy ONC deems appropriate.

Micky wrote:

"1)  Organizations with self-developed systems may depend on a HISP as part of their certification, but organizations with vendor-based EHRs will not
a.   Although organizations with self-developed systems may chose to use the HISP as part of their alternative certification, most organizations will rely on their EHR vendor's complete certification
b.   For example, for Beth Israel Deaconess Medical Center certification, the HISP, acting as modular certified technology, needs to generate MDNs in response to incoming messages.
c.   For everyone else, the HISP does NOT need to generate any type of MDNs.  Sending providers only need to have reasonable assurance that messages sent via the HISP have been delivered to the intended recipients.

2)      There are three requirements that are relevant here:  the transitions of care attestation requirement, the technology certification for receiving messages, and the technology certification for creating/transmitting messages:
a.       The Meaningful Use Stage 2 transitions of care attestation requirement is that “the summary of care record must be received by the provider to whom the sending provider is referring or transferring the patient” (see page 4 of the measure)
b.      2014 Edition certification requires that an EHR be able to receive a Direct-compliant message and send an MDN for successfully received message (see page 5 of the NIST test script)
c.       2014 Edition certification requires that an EHR be able to transmit a Direct-compliant message to a Direct address recipient.  There is no MDN requirement on the transmission certification.  (NIST test script).

3)      The MDN requirement is SOLELY a certification requirement (it is NOT an attestation requirement) and it applies only to the requirements regarding receiving messages.  There is no certification requirement for MDN in transmission transactions.  There is no attestation requirement for MDNs (or any other technical means) to demonstrate assurance of receipt of transmitted transitions of care.
a.     While attestation does require that the intended recipient actually receive the message, there are no requirements on what type of assurance the sending provider must have in order to meet the Meaningful Use transitions of care measure.  Indeed, the ONC commissioned white paper on the topic of assurance states that:  “It is up to the Certified EHR Technology vendor to determine how to assist its customers and provide them with assurance that transmissions have reached their intended recipients.  This assurance could include a presumption of success on the provider’s part of subsequent transmissions if they have reasonable certainty that initial transmissions were successful.”  (see page 2 of the white paper)

4)      The MDN issue thus applies only to organizations that are using alternative certification and using the HISP as relied upon software because they need to be able to meet the “receive” and “create/transmit” criteria.  It does NOT apply to users who are using off-the-shelf Certified EHR Technology to transmit Direct messages over the HISP.
a.      Any other organization with off-the-shelf Certified EHR Technology which wants to use the HISP for transitions of care transmission does NOT need the HISP to be certified
b.      Their own Certified EHR Technology will generate a Direct-compliant message and pass it to the HISP for delivery
c.       The sender will have met their transitions of care requirement at this point as long as they have reasonable assurance that the HISP delivered the message to its intended recipient
d.      This assurance could be provided by MDNs delivered back from the receiving EHRs, but it does not have to be, and indeed, since recipients are not required to be Meaningful Use compliant, many recipients won’t be able to generate an MDN anyway
e.      In any case, it is NOT a HISP responsibility to generate and transmit MDNs back to the sending EHRs (except in the case where the HISP is acting as relied upon software for alternative certification)

5)      Some organizations may want the HISP to be certified for their attestation purposes.  For the purposes of attestation, the HISP will be certified ONLY for “generate/transmit” and NOT for “receive”, and thus it has no obligation to create MDNs
a.       In order for the HISP to receive modular certification for “receive”, it would have to be able to display CCDA documents, accurately match patients, and consume structured information for medication, problems, and medication allergies.  That would require that the HISP to include EHR features beyond the scope of HISP operations.
b.      Any organization that would like to attest with the HISP could thus only use the HISP for the “generate/transmit” requirement.

6)      Regardless of whether the HISP is used as just a conduit (#4) or as a certified module for transmission (#5), the HISP does need to provide some type of assurance of delivery back to the senders
a.       The current plan for the Massachusetts State HISP is to send back MDNs to provide assurance of delivery, which is ideal – however, it is NOT required
b.      The HISP could assure delivery by contract such as a service level agreement
c.      And/or the HISP could make available transaction audit records back to senders periodically or on-demand"

Dispatch From a Mysterious Island

Whenever I travel on business, I try to take a few hours to explore the road less traveled.   Whether that's climbing Mt. Fuji, hiking the Aonach Eagach ridge in Scotland, or crossing the Baltic Sea in a kayak, there's always an adventure to be found.

During my current Asia trip, I sought the help of several friends in Japan to arrange the trains, planes, and boats that would bring me to the shores of Yakushima, Japan's first World Heritage site, to explore the island's cloud forest and volcanoes.   Some of my colleagues who've heard about Yakushima, call it The Mysterious Island after the Jules Verne novel of the same name.

If I were to design the perfect Mysterious Island, here are the characteristics it would have:

1.   The approach should be difficult and ideally involve a small plane flying through miles of cloud cover with no visibility.    Check, did that.

2.   Ideally, crossing an active volcano should be involved.   Check, did that.

3.   The forest should be ancient, filled with giant trees over 5000 years old.   Check, Yakushima is filled with Yaku-sugi, cedar trees that are thousands of years old with circumferences exceeding 30 feet

4.   Make it wet so that the entire forest is covered with moss and waterfalls.   Check, Yakushima has the highest rainfall in the world, over 30 feet per year.

5.  Put it in the track of many typhoons to make staying there exciting.  I just flew from the island into Typhoon Wipha - the photo below shows the swirling vortex of the storm creating a strange split level sky.  My hiking clothes are saturated despite total body Gore-tex.

6.  Make it dark and misty with 6000 foot cloud-covered peaks topped with snow in the winter.   Check, here are a few shots of the cloud forest I hiked.

7.   Fill it with unusual animals, insects, and birds that are found nowhere else in the world, including miniature deer and walking sticks that look like a cross between a centipede and spider.  Check.   It also has leeches, giant hornets, enormous spiders, venomous centipedes and poisonous snakes

8.  Add monkeys, it must have monkeys.  Check.  Yakushima has its own species of Macaque Monkey

9.  Give the plants an almost human look with long finger-like roots. Add vines and exotic flowers.  Check.

10.  Add forest spirits.   Admittedly, that only happened in the movie inspired by Yakushima, the Miyazaki anime called Princess Mononoke.   Almost check.

My visit to the Mysterious Island included 20 miles of hiking/climbing with a 6000 foot elevation gain including scrambling over moss-covered rocks during a typhoon.  I stayed in a wonderful place called  Wa no Cottage Sen-no-ie  handcrafted of cedar.  I highly recommend staying there if you visit.  The people who run it are remarkable and speak English.

I think a visit to Yakushima qualifies as the road less traveled.   Priceless.

Building Unity Farm - Reflections on our First Year as Farmers

While I'm traveling in Asia, my wife Kathy is running the farm, ensuring that all our animals are healthy, our last few harvest duties are done, and our preparations for winter have begun.

Before I left, I did everything possible to minimize her tasks.   I installed heating panels in the duck house so that she could move the duck babies from the brooder to the outside world.   I harvested mushrooms from all our fruiting logs.  I added yeast and nutrients to our fermenting apple cider.  I secured all our gates, cleaned the barn, and finished moving all our building materials into the hoop house.

Thinking about the past year, we're well on our way to a productive, self-sustaining farm.  Here's a status report

Mushrooms - we've gathered our first 25 pounds of oyster mushrooms from 144 poplar logs stacked in two forest locations.   We've finished inoculating Shitake spawn into 165 oak logs housed in the shade house plus 110 logs in the forest.   We've inoculated 10 logs with Lion's Mane.   Next year we should have commercial quantities of mushrooms to sell.

Bees - Our 8 hives built up their honey stores all summer , despite our harvesting of 160 ounces.   Our queens are healthy and the bees are disease free as we head into winter. Given the strength of our hives, we should substantial honey harvests next year.

Apples - we've placed an order for additional trees to add to the orchard in 2014
3 Kingston Black
1 Ashmead's Kernel
1 Newtown Pippin
1 Golden Russet
2 Wickson's Apple
1 Nehou
1 Baldwin
1 Blacktwig

bringing our total to 40 apple trees.   This year we crushed 250 pounds of apples and fermented enough juice for 75 bottles of still and sparkling hard cider.  Above is a look as the fermentation in progress.   In five years, we'll have nearly 7000 pounds of apples per year for eating, selling, and cider making.

Blueberries/Raspberries/Elderberries - our planting of 180 high bush/150 low bush blueberries and placement of permanent bird netting is complete.   The blueberries already yielded a few pounds, but we should have hundreds of pounds within a few years. The raspberries and elderberries should begin producing next year.

Alpaca/llama - Our 11 alpaca and 1 llama are in perfect health.  Two are pregnant.   They understand the routine of monthly "herd health" checkups and trust us to handle them with respect and gentleness.  The barn is fully stocked for winter with all the hay we need to last until next hay season.

Poultry - our 11 chickens, 31 guinea fowl (11 adults and 20 babies), and 10 ducks are completely adapted to their surroundings and the routine of going into their coops at night for protection.    Pecking orders are established, and our poultry community lives in harmony, eating wild foods throughout our 15 acres every day.   Our baby ducks are shown below.

Dogs - Our two Great Pyrenees are now fully grown and protect all our animals.  Admittedly since they weight nearly 200 pounds together, running with them (I weigh 165) can be an adventure

Hoophouse and Vegetable Garden - Our year round indoor and outdoor vegetable gardens are now complete along with watering, fertilizing, and harvesting infrastructure.   We'll grow lettuce, kale, and spinach all winter long.  Next spring we'll plant enough crops to supply half our food.

It's been a great first year on the farm and the daily activities caring for the animals/plants has become so integral to our lives that travel away (like my current responsibilities in Asia) seems completely out of balance.

Dispatch from China

This week I'm in Asia providing advice to government, academic and industry leaders about leveraging IT investments to accelerate quality, safety and efficiency policy goals.

I flew from Boston to Beijing on Monday to Tuesday and met a team of Chinese industry leaders on Tuesday evening to discuss their plans for smart cities, home care, and wired hospitals.

On Wednesday, I joined several colleagues to celebrate the opening of a new state of the art ambulatory care facility for women and children.  They are implementing EHR products to automate clinical and administrative workflows including provider order entry.   Mitch Rabkin and I keynoted a conference describing the US experience with healthcare reform and healthcare IT reform.

On Thursday (I'm a day ahead because of the 12 hour time change), we met with central government officials including the health minister of China.   We discussed a collaboration that would enable US and Massachusetts experiences to inform Chinese healthcare policymaking.  Of particular interest to them is our HIT Standards and Certification program to enhance care coordination, patient/family engagement, and population health.   As I wrote about yesterday in my post offering advice to the new national coordinator, I look forward to considering the revisions needed in our regulations to highlight the good and minimize the burdensome.   We have a great opportunity to apply our revised regulations to 1.3 billion people in China!

On Friday, we'll run a symposium on healthcare IT and care management in Hangzhou.   On Saturday we'll have meetings with government leaders in Shanghai.

Then on Sunday, I head alone to Japan for the next phase of my trip, serving as guest professor in Kyushu, the southern part of Japan and keynoting in Taiwan before returning to Boston.

One of the great aspects of working in Asia is that the 12-13 hour time change enables me to have a full day with colleagues in China/Japan/Taiwan then have a full day with colleagues in Boston.   Keeping a 24 hour a day schedule for two weeks will require a bit of recharging, so while in Japan I am taking a day to climb 6000 foot volcanos and hike the wilderness of Yakushima island, one of the great ancient forests in the world.   As I dash from Asian city to Asian city, my carry-on baggage contains my full body Gore-tex, enabling me to tackle the 10 meters of annual rainfall in the wettest location of Japan.   Probably the only downside to the remarkable beauty is the predominance of giant leeches.    You only live once.   I'll post pictures.

Advice to the Next National Coordinator

Over the next few months, Jacob Reider will serve as the interim National Coordinator for Healthcare IT while the search continues for Farzad Mostashari's permanent replacement.

What advice would I give to the next national coordinator?

David Blumenthal led ONC during a period of remarkable regulatory change and expanding budgets.  He was the right person for the "regulatory era"

Farzad Mostashari led ONC during a period of implementation when resources peaked, grants were spent, and the industry ran marathons every day to keep up with the pace of change.   He was the right person for the "implementation era"

The next coordinator will preside over the "consolidate our gains" era.   Grants largely run out in January 2014. Budgets are likely to shrink because of sequestration and the impact of fiscal pressures (when the Federal government starts operating again).    Many regulatory deadlines converge in the next coordinator's term.  The right person for this next phase must listen to stakeholder challenges, adjust timelines, polish existing regulations, ensure the combined burden of regulations from many agencies in HHS do not break the camel's back, and keep Congress informed every step of the way.    I did not include parting the Red Sea, so maybe there is a mere human who could do this.

What tools does the coordinator have in an era of shrinking budgets?

At present, Meaningful Use Stage 2, ICD-10, the Affordable Care Act, HIPAA Omnibus Rule, and numerous CMS imperatives have overlapping timelines, making it nearly impossible for provider organizations to maintain operations while complying with all the new requirements.  

Can resources be expanded? Given that Medicare/Medicaid reimbursements are falling, private insurance payments are nearly flat, and costs continue to escalate, the pie of resources is a fixed size and very challenging for anyone to expand.  

The new coordinator has only two levers - reduce scope or extend time.

Changing the scope of initiatives already in progress may be very challenging i.e. require acts of Congress, realignment of powerful stakeholders, or compromise of the important interoperability goals we've worked so hard to craft.

That leaves "time" as the one lever under the coordinator's control.  However, even revising schedules will be challenging because of competing stakeholder demands.  

a.  ICD-10 - although some large organizations have significant sunk costs and want the deadline to remain as October 1, 2014, smaller organizations will not be ready.   Some payers (including government payers) may not be ready.    It's clear we need to extend the deadline at least 6 months.    Maybe encourage voluntary ICD10 transactions on October 1, 2014  but allow a 6 month grace period without regulatory enforcement for the industry to catchup with the software, training, and process change needed for ICD-10 success?

b.  Meaningful Use stage 2 - Software products are still being certified, so many hospitals and professionals have not yet upgraded to Meaningful Use Stage 2 certified applications, making a 2014 reporting period/attestation somewhat challenging.   Meaningful Use Stage 2 reporting periods have already begun for hospitals, so no delay is possible, but the reporting period timeframe could be extended.   Maybe provide an 18 month window for Stage 2 attestation?  I realize this could delay future stages of Meaningful Use, but the industry needs a breather to consolidate our gains.

c.  ACA - the Affordable Care Act has motivated many organizations to focus on continuous wellness rather than episodic sickness.   ACOs are building private data exchanges and outcomes registries.  Progress is accelerating because every dollar spent on IT has the potential to reduce costs in risk-based contracts.  ACA and private insurer equivalent programs (such as the Blue Cross Alternative Quality contract) include many quality measures.  Unfortunately, these measures are not optimized for the EHR era and are retooled from a time when quality measurement was done by abstractors in health information management.    Rather than escalate already burdensome quality reporting requirements (BDMC produces over 1000 measures per year for various regulatory agencies), shouldn't we step back and ask what measures are truly important and urgent in a fully electronic era?   Reducing reporting burdens temporarily while s a consolidated set of new electronic measures is developed would be very helpful.

d.  HIPAA Omnibus Rule - audits require at least 10 operational hours for every auditor hour.  While hospitals and practices are in the midst of enhancing policies, revising infrastructure, and learning about the operational implications of the Omnibus Rule, it would be prudent to slow the pace of audits, just temporarily.  We all want to protect privacy and reduce risk but there is a fixed rate at which organizations can integrate change.   We need to focus on the long term and build a robust multi-layered defense.   At times in the past, we've moved faster with regulations/enforcement than standards and technology maturity could support.

e.  Some have suggested that if industry does move fast enough, more regulations will cause stakeholders to move faster.   I really believe that more regulations will be a case of haste makes waste.   Let's integrate existing regulations into the fabric of our operations, using the market forces created by the accountable care act to align incentives, and only consider new regulations when we have enough information about the impact of prior regulations.    Although challenging, maybe the coordinator could even consider polishing existing regulations to reduce the artificially burdensome aspects which are not necessary to achieve policy objectives.  I'd start with taking testimony about the certification scripts for view/download/transmit, transitions of care, quality measurement, automated numerator/denominator, and clinical decision support.

Jacob Reider will do a great job over the next few months and could become the permanent coordinator.   I will do everything in my power as co-chair of the Standards Committee to support whatever scope and timing revisions the coordinator considers.

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.

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.

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.

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.

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.

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.

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.

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.

Unity Farm Keets (Guinea Fowl chicks) Available Now

Our Guineas have been remarkably fertile this Summer and we'll have 100 babies available for purchase.   They're $4 each.

Guineas are tick eaters and will rid your yard of many undesirable insects.   You will need a coop to keep them safe from predators at night.

Our first hatching of 20 is extremely healthy and we'll have another 30 hatching this weekend.

Although chicks are shipped in general, our experience is that the process is extremely stressful for them.    Anyone wanting guineas should contact us at khalamka@gmail.com for New England (Sherborn, MA) pick-up.  Here are the details:

Straight Run (M/F) Hatched 8/20/2013
Pearl Gray (standard dark color)
Pearl Gray Pied (white chest)

Colors possible (Pearl Gray, Pearl Gray Pied, White, Lavender and Lavender Pied)
2nd Hatch on 9/3/2012
3rd Hatch (last for the year) on 9/18/2013
All will be well feathered by the time cold weather arrives

$4 each or 10/$30

Building Unity Farm - Preserving History

Since Sherborn's founding in 1652, the land of Unity Farm has been adjacent to the town center.  In the past, the property has been a dairy, sheep paddocks, and part of a much larger farm.   As I've cut trails through the property I've uncovered old tools, old timbers, and numerous rock walls.

Along the Unity Farm Marsh trail are two particularly interesting sights - the Sherborn Powder House and the Old Dug Well/Windmill.

The Powder House
The Powder House for Sherborn was built by the town in 1800 so that gun powder could be removed from the public meetinghouse where it had been stored, much to the relief of concerned citizens.  James Bullard was appointed keeper and the building was constructed in a meadow overlooking the lane behind his house at 33 North Main Street.  Although the actual building was demolished in 1857, the site of the Powder House is on our property.    The circular foundation is still in place and the rocks used to build up the walls are lying adjacent to the foundation.   An ash tree has grown up inside the former building.   Today, railroad tracks cross Powder House Lane in Sherborn, so the Powder House is no longer publicly accessible.      I've cleared the area, connected it to our trails and will be adding National Forest Service-like signage to it soon.

The Old Dug Well
About 100 feet south from the Powder House is an old, hand dug, brick-lined well.   When I first found it, the well was filled with 5 feet of mud, wood debris and midden.   What do I mean by midden?   As I began to excavate the well, I found 10 old milk crates, hundreds of pounds of old unmilled lumber, rusted iron tools, and an old menu board, pictured below.    Although fragments of the menu board are missing, it appears to announce "Great Steaks" like the "Powder House Tenderloin", Sirloin, Round, etc.  The lettering appears to be from the early 1900's.   I've asked Historical Society members about the well and steak sign.  Their only guess is that it might have been related to the old train station on Powder House Lane (no longer there) that used to be the major transportation hub in Sherborn.

Next to the well, an old windmill (blades shown above) provided the energy to pump the well water uphill to sheep grazing meadows.  

Since the well has now been restored to be a fully functional water source, I built a cover for it from 6x6 and 3x5 lumber.   We do not want wandering deer (or wayward teens) to fall into the well.   Our Great Pyrenees may not be as communicative as Lassie if Timmy falls into it.

Building Unity Farm - The Guinea Fowl are Born

It's August in New England and although everyone in healthcare IT is consumed by Meaningful Use stage 2, ICD10, ACA, the HIPAA Omnibus Rule, and various compliance initiatives, it's also the time we try to take a few hours off before the busy Fall.   Although I'm not taking any vacation this year, I have reduced my writing schedule (hence fewer blog posts this month) and spent more time at Unity Farm.

This week our first 20 guinea fowl hatched and the keets (the name for young guinea fowl) are running around the brooder, eating, drinking, chirping, and sleeping.

Here's how we did it.

Guinea fowl are terrible parents.  They lay eggs in a community pile and one female incubates them all.   Unfortunately, they tend to lay in the forest near fox dens, fisher cat habitat, and coyote trails.   We've lost several females this Summer but luckily found the nests and gathered the eggs before they were too chilled to be viable.

We placed them incubators at 100F and 50% humidity.   The gestation period of a guinea is 26-28 days.

Automated egg turners slowly moved the eggs for the first 23 days.  Then we laid them flat in the incubator, making it easy for the chicks to peck through the shells.

On day 25, one of the larger eggs started to roll, crack, and chirp.    A few hours later, a piebald keet was born  (Keets come in pearl black, white, grey, and piebald).

On day 26 and 27, the rest of the eggs popped like popcorn with little keets running around the incubator.   About an hour after birth we moved them to the brooder, a larger space kept at 100F with ample food and water.

Three of the 23 eggs did not hatch (hence the expression don't count your chickens before they're hatched), which is typical for game birds.   After verifying that there were no signs of movement, I carefully opened the 3 unhatched eggs and found that all  had developmental issues and an early demise.

The 20 keets that hatched are amazingly active, large, and robust.   Our batch of keets last year arrived in the mail and we had quite a lot of attrition.  There are definite advantages to hatching your own poultry.

Animal husbandry is hard and Guinea Fowl can be challenging, as illustrated by this great article in the Atlantic.

At 4 weeks, we'll move the guineas to the coop, but keep them from free ranging until 12 weeks.  We find that 2 months in the coop gives the guineas a chance to mature and be able to defend themselves agains predators.  It also firmly establishes the coop as their home and they'll return to sleep there every night as adults after a day in the forest.

We've gathered nearly 100 guinea eggs from forest nests and all are in our incubators.  Although we can keep 50 or so in our coop and sheds, we'll sell the others to local farms.   Given the significant increase in tick-borne disease across the country. we believe that guinea fowl, nature's most efficient tick eater, will be very popular with homeowners in the rural areas west of Boston.  

Guineas have become such a regular part of our lives that I cannot imagine a day without them.  Looking out my home office window, I expect to see the guineas running by on their quest for food and camaraderie.