our-yoga

ONC/CMS provides strong oversight of the Meaningful Use program by continuousy reexamining the quality of certified products and auditing hospitals and practices that have attested to meaningful use.

Last week, ONC "de-certified" a product for not supporting the functionality required by regulations .

Meaningful Use audits are done by Figliozzi and Company on behalf of CMS.   I've assisted one of our hospitals and one of our practices with such audits.

What do the auditors ask for?

*Proof of ownership of a certified EHR
*Reporting method used to incorporate Emergency Department (ED) patients (All ED Visits or Observation Services)
*Core and Menu Measure Meaningful Use Reports used to enter attestation data
*Documentation for “Yes” attestation measures to evidence the measure has been met
Based on the information received, Figliozzi and Company will prepare additional follow up requests as needed.  It's helpful to retain all supporting documentation used while preparing for attestation so that it can be readily available for auditor followup requests.  We've placed all our materials in a shared folder which is accessible to IT and Compliance staff.

The type of documentation we've stored includes

*Our Certification process and approvals (we self-certified our systems)
*Our actual attestation documents and receipts
*Reports from our EHR which reconcile exactly to the attestations made for each Core and Quality measure.
*Documentation for Public Health measures with confirmation emails from contacts at the Public Health Agencies
*A statement about change control and source code control systems which documents that functionality such as Drug/Allergy Interaction Checking, Drug Formularies and Clinical Decision Support Rules was enabled for the entire reporting period
*Documentation that explains the interpretations made by management for all measures.
*Documentation regarding the validation we did for quality and meaningful use measure reports

Most EHR vendors have experienced the auditing process and can provide letters/supporting documentation that Figliozzi and Company will find suitable as proof that proper procedures were followed.

I tell my staff that there is a process for everything and no matter how daunting/irritating an audit seems, you'll get through it if you maintain your equanimity and objectively respond to each request.

If you have not prepared or retained your Meaningful Use documentation, I recommend you prepare those binders and shared folders now.   You'll be thankful when the auditors arrive.

This morning, I had an interesting conversation in the coffeeshop I hang out at. I walked into the coffeeshop and was about to go over to the barista at the counter to order my usual morning espresso shot, when I spied a friend sitting on a couch in a corner, his face buried in his Iphone (hmm... many people I know seem to like burying their faces in Iphones: See previous post for another real-world specimen of Homo Iphoneopiens.) 

I walked over to my friend and greeted him, interrupting his communion with his Iphone. We chatted for a few minutes. He looked a little worn out, so I asked him if he had had a late night (this being a college town and all). He said yes, and that he had also spent the whole of yesterday helping some friends with some very menial tasks, as a result of which his muscles were feeling very sore and stiff.

On the spur of the moment, I asked him if he had ever tried yoga. He looked at me for a brief second, and then laughed. I told him that I wasn't joking, that I personally do yoga. "But I can't touch my toes! Heck, I'm not sure if I can even touch my knees! Can you touch your toes?" I responded by standing up, bringing my feet together, extending my knees, and then folding over to bring the heels of my palms to the ground (a.k.a. Dve position). "Ridiculous!" My friend exclaimed. "Yeah... and I'm not even warm!" I responded.

Anyway, having thus demonstrated my, ahem, ridiculous flexibility, I went on to explain to my friend that yoga is really a therapeutic modality, that physically (and maybe also mentally) inflexible folks need yoga more than flexible folks, attractive Yoga Journal models notwithstanding. My friend listened dubiously ("Yeah, that's easy for you to say, you who can touch your palms to the ground!" He was probably thinking...), but being polite, said nothing to contradict me.

My days of yogavangelism being behind me (see this post for more details on yogavangelism), I decided to cut my yoga sales pitch short, and we moved on to other topics (such as the recent landing of the Curiosity rover on Mars, and how the weaker gravity on Mars may make it easier for people to stretch, thus resulting in a yoga boom on Mars should humans ever succeed in colonizing the planet...).

Anyway... There's no moral to this story. It's just a random story from a rather random day in my life. More later.       

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Hmm... it's been a while, hasn't it? As you can tell, I haven't been blogging much lately; my last post was ten days ago, which is, to date, the longest length of time I have spent away from this blog... well, this is actually not entirely true: I have been checking in here at least once a day. I just haven't found the time or energy to actually write a post, due to a lot of work-related travel, and preparing for the things that I have to do during these travels.

Anyway, I'm back, for now at least. I don't really have much to say about my practice, or about much else, really. I brought Sharath's led primary CD with me during my travels, and just did my practice in my hotel room in accordance with his vinyasa count. It's very nice, actually; no need to think, no excuse to procrastinate or faff about practice. Just listen to Sharath's count, and practice along. Having Sharath's voice to listen to is also a good way to anchor yourself in a sort of timeless present when you are in a foreign place.

But actually, here's an interesting encounter I had yesterday that might be worth sharing here. On my way back home, I had a layover at Denver International Airport. As I was hurrying along to the gate to catch my connection, I glimpsed, out of the corner of my eye, a familiar face passing by. I couldn't be sure if he was who I thought he was, as I hadn't seen him in a while, and his face was buried in his Iphone, making positive identification that much trickier. But I decided to take a chance anyway; I extended my arm across that little fleeting expanse of space that separated us, and punched him lightly on the shoulder. He looked up, and a flash of recognition spread across his face, followed by a smile: It was indeed my friend and fellow Ashtangi Bill, whom I hadn't seen or kept in touch with for a couple of years since we attended Matthew Sweeney's workshop together in Minneapolis (for more details, see this post). What are the chances, meeting like that in not-quite-Denver? And imagine what would have happened to me if he had turned out not to be Bill?

Anyway, Bill, it turned out, had just flown into Denver (where he is presently living) from Sharath's workshop in Encinitas. As we chatted and tried to catch each other up on the course of our respective lives in the ensuing past couple of years in the few minutes I had before I had to run to catch my connection, I learned to my great pleasure (and frankly, also a bit of envy) that since Matthew's workshop, Bill had been to Mysore a couple of times, while I have yet to make it there. But well, it is what it is. No point fretting over things that did not happen. But it was also a very nice feeling to learn that both Bill and I were practicing to Sharath's count that same morning (he to the real Sharath, and I to the CD).

My chance meeting with Bill, as I mentioned, lasted only a few minutes before I had to go catch my connection. But it was a very pleasant surprise, nonetheless. There's something very magical about meeting a fellow Ashtangi in such totally serendipitous and, in some respects, totally incongruous circumstances (he was dressed in post-practice T-shirt and jeans, I was wearing a suit), especially in light of the fact that we could have just as easily passed each other by without even being aware that we were just within a few feet of each other. (Moral of the story: Don't bury your face in your Iphone when walking in airports?).

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Dear readers, yes, I'm back! After nearly a month away I have finally landed back home. In the time I've been away, spring has sprung and it is truly beautiful to see.

Although I haven't been posting, you have been reading, and I have a host of reader-requests from the blog that I will soon be turning into posts! So if you have left a comment recently, please know that I've heard you and I WILL be answering very soon.

In the meantime, don't forget to stop and smell the flowers!

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“Stop comparing where you’re at with where everyone else is. It doesn’t move you farther ahead, improve your situation, or help you find peace. It just feeds your shame, fuels your feelings of inadequacy, and ultimately, it keeps you stuck. The reality is that there is no one correct path in life. Everyone has their own unique journey. A path that’s right for someone else won’t necessarily be a path that’s right for you. And that’s okay. Your journey isn’t right or wrong, or good or bad. It’s just different. Your life isn’t meant to look like anyone else’s because you aren’t like anyone else. You’re a person all your own with a unique set of goals, obstacles, dreams, and needs. So stop comparing, and start living. You may not have ended up where you intended to go. But trust, for once, that you have ended up where you needed to be. Trust that you are in the right place at the right time. Trust that your life is enough. Trust that you are enough.”

- Daniell Koepke

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I skipped my Unity Farm post last week due to the events in Boston that required undivided attention.

2012 was the year of animals at Unity Farm since we acquired our herds and flocks from May to August of that year.   2013 will be the year of produce as we create the mushroom farm, orchard, and hoop house.

Last weekend, after the Marathon related events subsided I finished cutting the 220 oak logs needed for the Spring inoculation of 11 types of Shitake and the 72 poplar logs needed for cultivating 6 types of Oyster mushrooms.

Using 85% shade cloth, my wife and I built the 10x30 foot shade house pictured above.   As the logs are inoculated the weekend of May 11-12, we'll stack them in the shade house for a yearlong mycelium run.  Next Spring, when the spawn has grown throughout the logs, we'll place them in the forest for fruiting.

Also, last weekend, we continued orchard preparation by placing erosion control tubes around the perimeter of the recently cleared 2 acres in preparation for grading.   The orchard borders a 100 foot wetland buffer so we do not want sediment running off into the wetland.

We added topsoil and loam through the area to smooth the topography and amend some of the poor quality soil that was used as fill during the original house and barn construction.

We rebuilt rock walls that were scattered due to erosion and forest growth over the past 100 years.  Those rock walls now provide stability to the hillside and will serve as a terrace between the fruit trees and the blueberries.

Next week, we'll install 1000 feet of 8 foot deer fencing around the perimeter including 3 gates that enable travel on the new dirt road we've graded through the orchard.

In two weeks, we'll plant 30 trees, blueberries, raspberries, and orchard grass between the tree rows.

Finally, we'll add drip irrigation to all the new plants.

In early Summer, I'll build a 20x48 foot hoop house for 20 raised beds of vegetables and create a raised platform for bee hives.

By mid-Summer, we'll have completed all the foundational components for produce.  We will have delayed gratification on fruit tree and mushroom harvesting, but the hoop house will provide us a bounty of Fall vegetables and year round lettuce, kale and spinach.

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In June, BIDMC goes live with Electronic Medication Records (EMAR) on one ward to be followed
by 3 other wards, ensuring we meet our 10% Meaningful Use Stage 2 target by the reporting period October 1-December 31, 2013.

We built a web-based, mobile friendly EMAR system that includes many visual cues and seamless integration (not interfacing) with all our existing clinical information systems.

In modeling the workflow, we had to chose appropriate hardware devices to support various use cases.    Here's what we decided:

iPhones for mobile viewing of patients, upcoming medication tasks, and dashboards of medications given.

iPads mounted near the Omnicell devices for easy verification of medications to be dispensed.

Wall mounted computers with bar code readers on extension arms near each bed to enable easy scanning of patient wrist bands (bar code enabled positive patient ID), scanning of medications, and entry of confirming passwords.

Computers/Workstations on wheels (COWs/WOWs) as a backup only in the case of failure of wall mounted systems.  In general we've found that clinicians do not like COWs/WOWs because they are awkward to move around and also have to be recharged frequently.   They will only be used as backup systems.

The strategy is summarized in the graphic above.

We'll learn a great deal about the user experience by formally studying how often and when these various devices are used.   It will then inform our rollouts across the hospital.

We've also provided a few different user interface options for nurses including a "shopping cart" view of bar coded verified medications to be administered, a checklist which pre-populates the shopping cart with medications to be verified, and a grid of next doses that can be easily clicked to record administration or a reason for delay.

One of our residents has been assigned to document usage patterns and stakeholder feedback so that we can refine the user interface prior to broad rollout.

At BIDMC we build 25% of our applications and buy 75%.   EMAR is a perfect example of why we build.  How many iPhone/iPad friendly cloud-hosted web-based EMAR systems exist that are built by clinicians for clinicians with refinements to usability made after production experience?   We'll let you know what we learn in June.

This week, we at Yogayama are hosting David Robson while he facilitates an in depth study into the tradition of Ashtanga yoga. As you can guess, there is much to uncover when it comes to the simplicity of the practice, the most important part. With attending to the drishti  in each posture and the energetic components of bandhas and the asana, there's a reason why the wisdom of the practice only arises through doing it. However, taking the time to study each component with curiosity and contemplation builds greater awareness, hence the opportunity to immerse oneself into the practice of Ashtanga yoga. We are deeply grateful to David who has taken the time to extend his experience to the international students participating in the immersion.

David Robson is the co-owner and director of Ashtanga Yoga Centre of Toronto. With 100+ students each morning, he leads one of the world’s largest Mysore programs. After completing a degree in Comparative Religion, David made his first trip to Mysore, India in 2002, where he initiated studies with his teacher R. Sharath Jois. Since then he has returned annually to deepen and enrich his practice and teaching. David also teaches internationally. For more info visit www.learntofloat.com.

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Now that schedules are returning to normal, it's appropriate to review the events of last week and reflect on the lessons learned with the benefit of hindsight.

1.  Risk planning is forever altered

To me, risk is the likelihood of an event multiplied by the impact of that event.

Risk management for BIDMC IT now uses the NIST 800 framework, so areas of risk are formally enumerated, however, it still requires judgement about mitigation strategies.

At 2:50pm on April 15, seven BIDMC IT staff were volunteering in the medical tent/working at the Marathon finish line, a few feet from the explosions.   They were among the first responders assisting the injured.   Their work in a medical community gave them the strength to stay calm but could not have prepared them for the scenes of destruction they witnessed.   All my staff were safe and unharmed, but given their proximity to the bombs, the outcome could have been devastating.

As we think about risk planning in the future, we'll need to consider the events of last week when told something as innocent as "the  majority of the database administration team is going to volunteer at the Marathon"

2.  Secure remote access to all systems is critical to operations.

As we continue to enhance the security of our applications and networks, we're limiting remote access to those with a true need to use systems from off campus.    As the events of last week illustrated, we need to plan for future events which shut down the city for 5 days and require many people to work from home if travel is restricted or a "shelter in place" order is given.

3.  We need to consider restrictions on physical access to the data centers.

The restrictions on travel to and from communities plus restrictions on entering/leaving BIDMC were imposed with an unknown duration.   Our disaster recovery planning needs to include scenarios such as no staff able to enter the data center and no staff able to leave the data center.

4.  We may need to consider novel audit workflows.

We capture every lookup in real time and perform many analytics to ensure patient privacy preferences are respected.

We placed the following message at the top of our intranet for every staff member to see on every page:

"Urgent Reminder for All BIDMC Staff About Patient Privacy
Staff must completely protect patient privacy according to federal HIPAA regulations and BIDMC's own privacy policies. That means:
1. No sharing of ANY patient information through email, Twitter, Facebook, Flickr or other photo sites, any other social media, phone calls or conversations – or any other way.
2. Do not look at, or access by computer, medical records or other protected health information (PHI) or personal information (PI) unless you are authorized to access that information AND you need that information to care for the patient.
3. Send all media calls to the Communications Department or page the Media Relations staff on call.

Violation of these regulations and policies will lead to disciplinary action up to and including termination of employment.

Most importantly, thank you to the overwhelming majority of BIDMC staff who are doing an excellent job of keeping all patient information secure."

Might there be new workflows required in the future such that appropriate individuals are paged/notified within seconds after a lookup occurs?  In an emergency/mass casualty disaster, how can we balance the need for increased security/privacy and appropriate access with real time auditing alerts?

5.  The need for healthcare information exchange in a mass casualty disaster is very clear.

When patients have a choice of caregiver - a patient centered medical home or accountable care organization - a lifetime medical record is likely to be available, supporting safe, quality, efficient care.

The events of last week required patient routing based on acuity, urgency, and availability of resources.   BIDMC, Massachusetts General, Brigham and Womens, and Childrens did a remarkable job treating every patient even with incomplete medical information.   The Massachusetts Healthcare Information Exchange ("the MassHIWay") is currently in production for "pushing" summaries from organization to organization.   Last week's events illustrate the importance of our second phase, now under construction, for secure retrieval of information based on a record locator service and a patient consent registry.    By the second quarter of 2014, we should have the infrastructure in place to support the kind of data exchanges that would have been helpful last week - a first in the country kind of capability.

IT in general experiences more demands than supply.   Last week, we learned firsthand how technology can support a disaster. As we think about all the work on our plates,  our plans going forward must incorporate our recent experiences.

For Intermediate series students of all levels of experience. Take an indepth look both practical and philosophical into the internal evolution the Intermediate Series awakens. 

Intermediate Series, otherwise known as nadi śhodana, meaning nervous system cleansing, builds upon the culmination of energy and purification within the practitioner built upon the foundation of Primary Series. With deeper backbends and forward bends as well as arm balances, the Intermediate series integrates the use of opposing forces to garner greater unity and strength, both mental and physical, opening the internal light of awareness within each individual. 

In this workshop special attention will be focused on the in depth study of each posture, their relationship to each other as well as executing the proper vinyasas and transitions, with special attention to all points of Tristhānam (posture, breath, drishte) throughout the practice. In addition, there will be time taken to trouble shoot areas of difficulty gathering skills to move forward in the practice with greater intelligence and awareness.

Whether new to the practice of Intermediate Series, or an experienced practitioner, this workshop will invoke new insights and inspire your already existing practice. 

Date: 11 - 12 May 3013

Time: 14:00 - 16:30

Location: Yogayama, Jungfrugatan 8, Stockholm, Sweden

To Book: www.yogayama.se

Investment: 600 sek

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Eating fire
is your ambition:
to swallow the flame down
take it into your mouth
and shoot it forth, a short or an incandescent
tongue, a word
exploding from you in gold, crimson
unrolling in a brilliant scroll

To be lit up from within
vein by vein

To the sun

- Margaret Atwood


Unpacking the subconscious. There is really no way around it and lately I've had no other choice but to unload. My dreams tell all, with a cast of characters I'm surprised have made an appearance. Sometimes when doing this work it feels like I've taken a million steps backward. An unending cycle. I guess it goes with the nature of what one of my past mentors told me. When we grow and exude more light, it has a tendency to show our dark spots even more clearly. Makes sense. It isn't always pretty but I've been left with no other choice really. With this, memories having been bubbling up to the surface in an aggressive fashion. Things I don't think I have fully processed and the emotional baggage that comes with it. I don't want to be numb to it and at the same time it can be confusing trying to decipher what lays behind it all. In a day and age where everyone has tips and tricks of the trade I state it clearly now, I don't know if I am equipped to handle it in a productive way but at least I'm feeling what I need to feel. I don't have all the answers. I don't know all the whys, but I do my best to show up to it as I lean into the uncomfortable areas, accepting responsibility for where I am now no matter the challenges I've experienced. And who would've thought there were still resentments buried deep beneath the surface.

When I arrived back home from India this year I felt myself yearning for what lacked in my childhood. Strange, I know. I had no idea it was there so deep within my subconscious, because when I was young I knew how to put on the face that all was fine, and essentially I thought is was, never minding the deep sadness that laid beneath the surface. A survival mechanism that held me together in times of need but in the end can weigh heavily if never fully accessing the gravity of what needed to be eventually felt. The defense mechanisms had their purpose and the challenge is to put them away when growth is necessary. This yoga stuff really works. It's not always about bliss and peace of mind, its also about keeping watch over what arises within because what we are really doing is undoing. 

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The April HIT Standards Committee focused on refining the work plan for 2013, ensuring that standards work is appropriately divided among SDOs, S&I initiatives, and HITSC committee workgroups.

Doug Fridsma presented ONC's recommended next steps, based on the feedback from the HITSC Workgroup chairs.  

In an hour long briefing call two weeks ago, the HISTC Workgroup chairs evaluated each HIT Policy Committee request for standards and suggested to ONC those standards harmonization activities, hearings, and educational sessions  that would be most helpful.    ONC incorporated all the recommendations of the chairs into its go forward planning.

The entire committee agreed with the plan, which includes agenda for the next several Standards Committee meetings, the scheduling of expert testimony, and a dialog with the HIT Policy Committee to seek clarification about several requests.

Farzad Mostashari then gave introductory remarks describing the budget request for ONC's work which is modestly higher than its 2012 request and has not substantially changed since 2007 despite a doubling of responsibilities.

Jodi Daniel presented an overview of ONC Policy and Planning efforts highlighting advances in testing tools, the HIE RFI, and LTAC/Post Acute Care IT adoption.

Doug then updated the group on the ONC Office of Science & Technology Plan for 2013
including S&I initiatives, implementation guide development, and new tools available to support the process.

Clinical Trials, Clinical Research, and quality measures often require structured data capture from providers and patients.   Evelyn Gallego and Doug Fridsma presented the structured data capture initiative which will require some basic ontologies in order to ensure data elements are comparable across studies and institutions.

Micky Tripathi joined by phone and summarized the HITPC Information Exchange Workgroup comments on the CMS/ONC RFI on Interoperability and Exchange.   His comments about payment policy incentives, infrastructure enablers, and state-level program opportunities was very well received.

Finally, Mary Jo Deering and Kory Mertz updated the committee on HIE Governance efforts including two cooperative agreements - New York eHealth Collaborative and DirectTrust to pilot standards and trust fabric approaches that may be scalable to the entire nation.

A very positive meeting.   Given that HITSC was created by ARRA (legislation), it will not sunset because of an administration change, as happened to HITSP.   I proudly concluded the meeting by noting that our work plans will continue to be filled with opportunities to accelerate interoperability for the next several years.

I'm having a lot of fun following the recent conversations in the blogosphere about whether or not yoga is self-expression. In fact, I had so much fun that I even ventured to give my two cents' on this subject yesterday. Which is not something I have been doing much of lately. I don't want to jinx myself here, but I have this good feeling that blogging about this subject is helping me to get my blogging mojo back after what has essentially been a rather lack-luster few weeks of blogging. But we'll see.

In any case, continuing with the whole yoga as (not) self-expression conversation, I just read the latest post on the Babarazzi about this subject. As always, the people at the Babarazzi (what do they call themselves? "Babs"?) have pulled off a scathingly witty critique of contemporary commercial yoga culture; which is something that I, with my long-winded ponderous meandering writing style, can never hope to aspire to. In this latest post, the Babs make the following astute observation about commercial yoga culture:

"It’s pretty hard to find moments when we aren’t expressing ourselves. For instance, when we help a homeless man covered in a million bags hop a turnstile, we’re expressing our love of a thrifty deal... Self-expression seems to be a pretty f’ing constant occurrence.

Commercial yoga culture uses the ubiquity of self expression as a way to make yoga culture forever relevant to consumers by defining “yoga” as the very thing we can never not do. It’s a wondrous logical coup that allows commercial yoga culture to package and sell back to consumers whatever it is they want, and at the same time call it “yoga.” Think about it: If self-expression is all we ever do, and yoga is self-expression, than yoga is by definition anything you ever feel like doing.

• If painting is a form of self-expression, than painting is yoga.
• If dancing is a form of self-expression, than dancing is yoga.
• If singing is a form of self-expression, than singing is yoga."

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Many reporters have contacted me today for an IT perspective on the April 15 bombings in Boston.  

Within moments of the event, social media became the preferred mechanism for communication and coordination.   I was on a plane from Los Angeles to Boston at 36,000 feet when the bombs exploded and received real time twitter feeds, streaming video, and email from staff via GoGo WiFi.

As my experience illustrates, the most critical IT responsibility immediately after the event was maintaining robust, reliable, and secure infrastructure.  Given the peaks in traffic flow for communication and social media applications, many systems, such as the cell phone networks, were taxed beyond their design limits.   BIDMC networks, servers, storage, and client devices scaled well and there was no interruption of service.

Here's what my Director of Support Services said about the IT response on Monday afternoon.
 
"The IS Manager on Call was in phone contact with me within 20 minutes of the explosions.  Staff covering the Computer Operations/IS Alerting function did a great job.  Our desktop staff was paged by the BIDMC Command Center seeking media services support for LCD displays/projectors. The Emergency Response folks located the Command Center on the West Campus because of the ED activity (they usually locate it on the East Campus during storms, etc.).   We stood ready to deploy additional equipment but the Command Center was stocked with everything necessary.   We check and maintain Command Center equipment on a monthly basis.

I was in touch with all my managers and staff by 4pm.   There were no open IT issues.

We initiated a fan-out call list just to check on IS staff wellbeing – but also in case we needed them to come into the operations center for any reason.

Aside from the shock and eventual anger we all felt at having this happen in our home town, it was a typical operational day."

We continue to support our hard working doctors, nursing and staff who are treating  21 injured patients of which 7 are considered critical.

I'm sure there will be many lessons learned by the time these events have passed.  I will definitely post my experiences and reflections.