Thursday, November 27, 2014

Unity Farm Journal - Thanksgiving 2014

As a vegan farmer in a vegetarian household,  I’m always asked some thoughtful Thanksgiving questions.

“How do you serve Guinea Fowl?”

This is a very challenging question to answer because there is not much literature on the subject.   We serve all our 100 animals on Thanksgiving.

Two major issues when serving any guest  - where do you serve them and what do they want to be served?

Should we have an adult table, a kids table, and a guinea fowl table, since the birds tend to be noisy and messy?

To answer that question, I offered the poultry a choice of tables, chairs, walls, and logs.

As you can see below, the chickens prefer tables/chairs, while the guineas have a distinct preference for roosting in groups on walls or clusters of logs.

Guineas are herd animals, so when you send out invitations, you can be assured all will attend.   We have 68 guineas, so we’ve set up benches where they can sit while they are waiting to be served.

This morning I cut fifteen 18 inch lengths of maple logs and built 5 roosting areas so that the guineas can cluster with their friends and relations while we’re serving them.

These West African birds have different tastes than other poultry.  Some say Guinea fowl have tastes like Chickens and Ducks, but I do not think that is true.    As a test, I offered scratch grains, tasty mealworms, and fresh carrot tops to all the birds.

The chickens preferred the grains, the ducks preferred the greens, and the guineas ate the mealworms.

So the answer to the question about how to serve guinea fowl - create clusters of logs covered with mealworms.    Our guineas had a great Thanksgiving, along with all the other citizens of Unity Farm.

Happy Thanksgiving!

Thursday, November 20, 2014

Unity Farm Journal - Third Week of November 2014

The polar vortex has arrived at Unity Farm and it’s 20F.   All standing water has frozen and all outdoor plants have gone dormant.    The ducks are confused by their frozen pond but the Great Pyrenees and Alpacas are loving the cooler temperatures which approximate their native mountain environments.

As I’ve written about in previous years, preparing for winter on a farm takes a lot of planning.   All drinking water is now in heated buckets.    Wall mounted heating panels in the coops keep the birds from freezing at night.   Perennial beds are covered with salt marsh hay to insulate them from the ice and snow to come.

All fruits and vegetables are picked and the hoop house has been reduced to those greens which germinate and thrive at lower temperatures.    Although it’s 20F outside, the soil temperature of the hoop house is still nearly 60F.   Lettuces, mache, spinach, carrots, chard, kale, broccoli, brussels’ sprouts, radishes, turnips and beets all tolerate the early winter.     Here’s a view of the fresh vegetables still thriving while the weather outside is frightful.     We’ll have plenty of fresh foods for Thanksgiving.

We have placed temperature sensors in our outbuildings and growing areas for real time telemetry monitoring during the winter.    The chicken coop and duck house stay about 10F warmer than outside temps.   The hoop house gets up to 80F on a sunny day.

Now that the farm is prepared for winter, the nature of the work changes.    There is some vegetable harvesting in the hoop house left to do, but the bulk of my work in the upcoming weekend is keeping the flora, fauna, and family warm.   I've split 10 cords of wood and stacked it in our wood processing area, organized by species - cedar, oak, maple, black birch, ash, and hickory

After a summer of 16 hour days, we're looking forward to the hibernation which is winter in New England.   We'll catch up on conversation, indoor tasks, and  emotional recovery after the recent death of my father in law.

Wednesday, November 19, 2014

The November 2014 HIT Standards Committee

The November HIT Standards Committee focused on “asynchronous bilateral cutover” - the compatibility of different CCDA payloads, healthcare IT that supports long term services and support,  an update on the Standards & Interoperability projects, a discussion of data provenance efforts, and the HITSC workgroup organization.

We started the meeting by thanking Jacob Reider, Deputy National Coordinator, for his chairmanship of the Standards Committee.   He’s leaving ONC at the end of the month. He will be missed.

Charles Parisot provided an analysis of Consolidated-Clinical Document Architecture (C-CDA) Version Migration and Cutover Findings. The good news - many vendors can successfully generate and parse different CCDA versions.   We discussed two key takeaways.  When new versions of standards are introduced attention needs to be paid to backwards compatibility.  A bit of planning now can save significant EHR engineering complexity later.    Also, at some point, certification will need to codify what it means to be backward compatible.   Are older versions stored as human readable documents instead of structured data?   The HITSC members recommended to ONC that they seek the input of the EHR vendors as to the appropriate path for historical CDA variants (CCD, C32, CCDAr1, CCDAr2).

Next, Evelyn Gallego briefed us on the S&I Framework Initiative Electronic Long-Term Services and Support (eLTSS) .  This is a new initiative and it seeks to provide electronic tools for individuals with physical, cognitive, and/or mental impairments who never acquired, or have lost, the ability to function independently.   The committee discussion recommended that this work be done as “apps” outside the EHR, since it will likely incorporate data from several data sources and be used by stakeholders other than clinicians.

Steve Posnack updated us on Standards and Technology activities including new certification refinements.   He also provided valuable summary of ONC’s FHIR related efforts.   The alignment of government, industry, and academia around FHIR is truly a perfect storm for innovation.

Julie Chua and Jonathan Coleman presented the S&I Framework Data Provenance Use Case.  The committee recommended that this work be significantly narrowed in scope to achieve an implementable single use case which will inform the technology path forward.

Finally, Steve Posnack presented a HITSC Workgroups and Operations Discussion .   When the workgroups were reorganized there was concern about siloing - how do we avoid multiple duplicative work streams in the various workgroups.   Steve’s answer is to draw members from each workgroup into an ad hoc task force when multi-disciplinary problems need to be solved.  Thus, going forward, we’ll have some projects that are driven by workgroups and others addressed via ad hoc task forces of experts.

A good meeting.   We all look forward to the upcoming 2015 meetings in which we’ll review ONC’s 10 year interoperability roadmap and the next Notice of Proposed Rulemaking for Certification.

Friday, November 14, 2014

Unity Farm Journal Second Week of November 2014

The mood at Unity Farm has been somber this week with the death of my father-in-law on Sunday.   He was a significant part of seasonal farm activities and was a kind of third parent to my daughter.    His death from pancreatic cancer was so rapid that we’re all stuck in the first stage of grieving - denial that it happened so fast.

We find ourselves still calling for him to come to dinner, and expecting him to be sitting in his Morris chair as we gather around the hearth in the evening.   He will be missed.

The duties of farming - seasonal preparation, animal care, and the harvest do no wait for anyone, so despite our grief, we must continue with the routine around the farm.    We have pressed the last of our apples - about 450 pounds and now have 25 cases of hard apple cider in our fermenters.    I have applied for a bonded winery license so that we can sell Unity Farmhouse Cider.   Although this year was 25 cases, as our apple trees mature we’ll be able to produce about 200 cases per year - about 400 gallons.

We had our first snow this week and the temperatures are consistently below freezing at night.    We’ve blown out all the orchard irrigation and all above ground hose bibs.   We’ve prepared our ponds for winter mode.     We’ve blown a few tons of leaves from the barnyard to the forest.   We’ve harvested the last of the tomatoes, peppers, and eggplant.   All that remains in the hoop  house are greens and root vegetables - spinach, chard, cress, japanese mibuna, carrots, turnips, radishes, and beets.

The manure must be moved from the composting area before it freezes solid and we’ve created windrows below the orchard with the first 5000 pounds of it.

The farm will slow down a bit December-February as we turn our attention to indoor tasks -  skirting alpaca fiber, pickling/preserving the harvest, and planning for next season.

The alpaca/llamas, great pyrenees mountain dogs, and poultry are ready for the cold ahead,  having grown their winter coats/feathers.   The wood is stacked, the pantry is full, and every building has been prepared for stormy weather.

With all the events of 2014, time indoors for reflection, planning and rest is welcome.  We’ll schedule a time for my father-in-law’s memorial service when all the family has assembled for the holidays and celebrate his life surround by the bounty of our second year harvesting at Unity Farm.

Monday, November 10, 2014

Becoming the Oldest Living Generation

My father in law died yesterday.   His final days were surrounded by family, without pain, and guided by his wishes.   He spent 1 day in the ICU, 1 day in a hospital ward, and 1 day in hospice.   The journey from eating dinner with the family to death was 1 week.   His neuroendocrine pancreatic tumor was highly aggressive, and caused rapid weight loss, muscle wasting, and the inability to swallow without aspirating.    His path from life to death was just as I would want for my own - basic hydration, antibiotics for reversible infections, and a comfortable/caring environment with those closest to you standing by.

His death follows my father’s death a year and half ago.   That leaves only my mother as the living link to prior generations.   It means that I’m the oldest living male in the family.    In your 50’s it is common for you  to manage the declining health of parents.   It does feel early in life to become the oldest living generation.

Having worked with the transition of two fathers in two years, there is much I have learned about preparing for death

*Clearly document your wishes/preferences for physician orders for life sustaining treatment
*Ensure financial resources are well documented and understood by family members - bank accounts, retirement plans/pensions, and trusts
*If bills are unpaid, tax returns unsubmitted, or decisions unmade, ensure that a box of “to do” items is centralized.
*Making decisions about funeral arrangements is key
*Hospice is a good thing

My father and my father in law both benefited from caring/compassionate care in a hospice setting.    Hospice staff place the patient’s comfort first, reducing pain, alleviating anxiety, and providing a soothing environment.      We all die.   Spirituality aside, we’re a collection of biological systems that fail.   As walking fails, then eating fails, then thinking fails, vulnerability increases and control is lost.

A unified family, guided by the wishes of the patient and supported by a hospice setting brings a dignified, respectful death.  

All the emotion I expected was easier as the living members of the family gathered together for support.   Group hugs and gentle conversation helped calm the tears.

Over the next few weeks, there will be infinite details as accounts are closed, legal documents are executed, and the physical items associated with life are disbursed.   The death of a parent is never easy, but I am confident that the experience of my father’s death and the preparation for my father in law’s death will make the process as manageable as possible.

Thursday, November 6, 2014

Dispatch from Europe

I’ve been on the road for the past few days, describing the importance of patient and family engagement using mobile applications to healthcare leaders in Europe.  

The dialog has been bidirectional.  I learned a great deal about the technology and policy challenges in each country.   Patients, payers, and providers are struggling with issues such as usability, security, and supportability.  

My schedule has required several time zone changes - a keynote in Seattle on Saturday, a flight to London on Sunday for meetings with NHS leaders on Monday and a keynote in Birmingham on Tuesday.   In my discussion with UK leaders, they invoked the Chatham House Rule, something I had not heard about previously.  To encourage open dialog, anyone who attended the meeting was welcome to use information from the discussion, but not allowed to reveal who made any comment.

In the UK, I heard a great deal about misalignment between IT departments and clinicians.  IT departments are reluctant to embrace social, mobile, analytics, and cloud, instead insisting on centralized command and control of Windows desktop devices, often running Citrix/Virtual Desktop. Clinicians want mobile devices, universal access to applications anytime from anywhere on any device, and big data visualizations.   There is innovation, with forward thinking firms creating novel mobile apps and piloting them in several NHS sites.

In Berlin, I met with a diverse array of stakeholders from the entire EU and Russia.   All are facing the challenges of an aging society, chronic disease, and rising costs.   Several expressed frustration with the pace of healthcare IT innovation in Europe.  Regulators and IT departments are reluctant to be early adopters.  Windows and client/server platforms predominate.  Despite extraordinary engineering in Germany, there is still a fear of technology change.

Today marks the end of my travel for 2014.  I’ve cancelled planned speaking in Copenhagen and Amsterdam to support my father-in-law’s care.    As in previous years, my international collaborations have demonstrated to me that all our societies are making healthcare IT progress, but there is still a sense of urgency to do more.   Technologies move faster than politics and culture.   The work of John Kotter remains true in every location I visit - there must be a leader with vision, a guiding coalition, a reason for change, and an incremental step-wise approach to an idealized future state.    No technology, no matter how magic, can succeed without change management.

Tuesday, November 4, 2014

Unity Farm Journal - First Week of November 2014

When you’re a farmer, you’re often faced with the life, death, and sickness of those living things who depend on you.

Recently, my father in law was diagnosed with a Stage IV Neuroendocrine Tumor on the head of the pancreas.  Ironically, it’s the same disease that Steve Jobs experienced.   Chemotherapy began this week and we’re hopeful that shrinking the tumor will relieve some of his symptoms.   Cure is unlikely and many difficult decisions await us.

With Stage IV cancer, surgery is not an option.

If we do nothing, the highly aggressive tumor will cause rapid decline - weight loss, weakness, and susceptibility to falls/infections.

If we proceed with full cycles of chemotherapy, there may be reduction in tumor burden improving life quality or there may be side effects that make the situation worse.

We’ll work hard to respect all of his wishes on the journey ahead.  Chemotherapy and medications are meant to be palliative.   If complications occur, it’s likely that he will want minimal intervention.

He lives at the farm and needs to climb a few stairs, which is increasingly difficult,   We’ll need to think about mobility solutions, home care assistance, and possible relocation of his living spaces to the first floor.  We’re heading into cold and icy weather, so likely we’ll have to build a wheelchair ramp in and out of the house.

Having experienced the death of my father in March of 2013, the end of life process is still fresh in my mind.     As Atul Gawande outlines in Being Mortal, we’ll focus on life quality, not quantity.    My father-in-law and the dynamics of the entire family are paramount.     We’re rethinking the pattern of our duties and our activities.  I return to Boston from Europe tomorrow and I will not travel for the remainder of 2014, deferring all distant meetings and speaking responsibilities.   We’ll take each day one at a time, and I’ll creatively juggle my time using Skype, FaceTime, and teleconferencing to balance home/family needs with work needs.   My colleagues and BIDMC leaders are all very supportive.

Each of us will die.     The goal is to ensure that death is dignified and pain free.     My wife’s battle with breast cancer led to remission.    My father-in-law’s experience of pancreatic cancer will include the entire spectrum of emotion, from sadness to love and hope.   For now, medication, hydration, and spending time together is the most compassionate care we can deliver.