Unity Farm Journal - Fourth Week of July 2015

Kathy and I have been hard at work with our University of Massachusetts coursework on farming and sustainability.  Our first course, Post-harvest Handling of Fruits and Vegetables,  has been a rigorous combination of science and practical experience.    The online learning content is complemented by real world assignments.   Last weekend, we were to acquire the fruits/vegetables  we eat in a week and then sort them according their genetic, metabolic, and storage characteristics.  

When you live on a farm, there’s no need to drive to Whole Foods, you just grab a picking basket.   Here’s what we picked last Saturday morning.

The analysis involved separating these vegetables and fruits (tomatoes) into categories for storage in our 4 different cooling zones - our commercial walk-in refrigerator, residential refrigerator, root cellar, and mud room.

Here’s the completed analysis.   Let’s hope we survive the grading process!

This week, I’ve been redesigning the barnyard based on the workflow and processes we’ve implemented over the past two years.  How do you provide four seasons of animal and plant care with the following equipment (length x width x height in feet)

Terex Front Loader plus Snowblower attachment  12x5x7
SnowEx Sand spreader 5x3x3
Campbell Hausfeld Power washer 3x2x3
ExMark mower 7x4x3
Small farm cart 3x4x2
Medium farm cart 3x4x2
Large farm cart 3x4x2
Mobile Hose winder 2x3x2
SuperSplit Log Splitter  8x3x4
Manure cart 2x2x2
Wallenstein Chipper/Shredder 4x4x4

Answer - put it inside a 24x17x10 hoop house next to the barnyard that will serve as an all weather equipment depot.  

I’ve cleared the entire area behind the duck house and chicken coop of wood, manure, and planting supplies so that we now have a 100x50 foot section of flat land.

Over the next few weeks, I’ll haul gravel to create an all weather driving surface in and out of the hoop house while also preparing for a possible future pig housing area where the wood is now stacked.    Manure management will be done with a cart with a 1000 pound capacity that I can haul behind the Terex.

August is a great time on the farm - warm weather with limited planting/harvesting, so there’s time to do design work.

I’ll keep a photographic record of my progress.

When the Healthcare System Works

I was recently at a meeting where a colleague described a recent interaction with BIDMC.

She had a traumatic injury on a weekend afternoon and suspected a fracture.   Rather than visit an emergency department filled with high acuity patients, she visited the BIDMC Urgent Care center, knowing they could do imaging and place a cast if necessary.

The facility is within a few minutes of her home and the parking is free.  She was seen within a few minutes and x-rayed.   The emergency physician on shift apply a cast, and arranged a followup appointment with a specialty orthopedist at BIDMC, Boston.

The next morning, she received a call from the urgent care center asking if her pain was under control and if she felt any numbness/tingling from the cast (no).  She was also asked if the followup appointment was still convenient.   She asked if it could be changed to the BID-Needham location as that was closer to her home (and the parking is free).   The appointment was made instantly for the following day.   A permanent cast was placed and the orthopedist will care for her until she is fully healed and functional.

The entire care process was documented electronically and available to the patient via smartphone, including the clinician notes.

As I’ve written about several times in the past, this “care traffic control”, directing the patient to right intensity of care, then closing the loop for followup care is the future of medicine.  It’s high quality, lower cost, and improves outcomes.   The IT systems required to do it are more about workflow and process than the simple capture of records.   As we envision the next generation of electronic tools, support for team based care with handoff management and closed loop communication among the stakeholders will be the most important new features.

Here’s a personal example of another way the healthcare system should work.   As I mentioned last week, I have an arrhythmia for 15 years, but it has never been captured.  Last week I put an ECG monitor from AliveCor on my phone.   Over the weekend, I was able to capture a Lead I tracing of the arrhythmia on my phone, send it electronically to my PCP and Cardiologist, and receive a recommendation for next steps - all within an hour.

Here’s the tracing of the arrhythmia, which has a rate near 160 beats per minute.  p waves are present, so it’s an atrial tachycardia, which is benign (as opposed to a ventricular tachycardia which could be life threatening).    It could be atrial flutter, but I think that is unlikely because I do not have any underlying heart disease.

Here’s the tracing of my baseline ECG, normal sinus rhythm without any abnormalities.

My cardiologist recommended beta blockers or calcium channel blockers.

My PCP noted that my problem list now has three things on it

1.  Glaucoma
2.  New onset hypertension
3.  Atrial Tachycardia
4.  History of Lyme Disease  (now Western blot negative, so it is resolved)
5.  Low vitamin D (easily fixed with 2000 units of Vitamin D per day)

Beta blockers will improve the glaucoma, treat the hypertension, and prevent the atrial tachycardia.   I’ll see my PCP tomorrow morning and be started on beta blockers.

All of these interactions were done from my smart phone, with telemetry provided by me from a wearable sensor.    No phone calls, proprietary equipment, or paper-based records were involved.    I have an electronic record of the entire interaction.

Next steps for me including recording the arrhythmia with the AliveCor device while measuring my blood pressure with the Withings BP cuff.   During the tachycardia episodes I am lightheaded, likely due to low blood pressure.

From an IT perspective, I’m reaching out to AliveCor to determine if we can upload the ECGs directly into the BIDMC electronic record, just as we do with blood pressure and scale data with our new app BIDMC@Home.

I look forward to healthcare system that combines electronic tools, patients/families, and navigation by a team captain to all the right resources.    It’s not just a dream, it is beginning to happen today.

Unity Farm Journal - Third Week of July 2015

In yesterday’s blog post, I wrote about mobile devices and my own blood pressure variability.  

The one time that my blood pressure is normal is during a day of farm work.   After hauling wood, planting/harvesting, caring for animals, maintaining trails, and repairing infrastructure, I’ll walk down our farm road through the orchard on the way back to the house.   All the tension of the week fades away with walk along the road.

Last week we moved 10,000 pounds of manure from the barnyard compost area to wind rows near the orchard.   We use “llama beans” to amend the soil in our hoop house and supplement our trees/squash beds.    A heavy rain made the manure very heavy and on the way to the wind rows, a buried underground stump collapsed, causing the Terex front loader to tip over with a 1000 pound load.    Luckily I was standing nearby and the opened the emergency exit for the driver who exited unharmed.   We used a truck and heavy duty nylon webbing to pull the Terex back into the upright position.   No harm done!

With the manure cleared, we’re redesigning the barnyard so that we can install a 17’x24’ hoop house for equipment storage - moving the Terex out of the barn and the mowers out of our pasture lean-to’s.    We’re also creating an area that might be used for pigs in the future.  We’ve scaling back our wood storage to just 4 cords (from 8 cords).   We’re re-grading/leveling the barnyard and applying gravel to the working surfaces to minimize the low spots that become mud wallows.   With every passing season we’re learning more about how to run a farm and optimize the physical arrangement/equipment to minimize maintenance tasks.

We did our annual vet visit for a full physical exam of all the animals this week.   The 14 camelids (alpaca/llama) are entirely healthy.   We gave the rabies and clostridial vaccines, checked their nutritional status, and carefully examined eyes/ears/teeth.    The only issues were that the llama is slightly overweight (but no change from last year) and one of our older alpaca has irritated eyes that we’re treating with ophthalmic ointment.   Our young alpaca continue to grow like weeds.   Danny (4 weeks old) is now 35 pounds and Sunny (1 year old) is 85 pounds.

The geese continue to follow us around the farm.  It’s as if we have 5 dogs - two Great Pyrenees plus 2 buff geese and 1 tuft goose.

The young chickens are learning the ropes of farm life, roosting in the coop night, staying safe from hawks during the day, and avoiding conflict with the other birds.

At midsummer, the hoop house is filled with peppers, tomatoes, cucumbers, eggplant, and beans.  I fill a basket with fresh food every night.   Kathy is busy pickling and preserving the foods we’re not eating now.

The weekend ahead includes harvesting our garlic, potatoes and squash.   I’ll plant a few beds of lettuce and chard for early Fall picking.     We’ll spin frames of honey and bottle in anticipation of mead making and honey lager brewing this Fall.

I’m working remotely on Mondays and Fridays in August.   Although it seems early, the planning for harvest and the winter ahead is already in progress.

Patient Generated Healthcare Data

I’ve often written about the IT strategies of Accountable Care Organizations and the need for a Care Management Medical Record which incorporates EHR data, patient generated data, customer relationship management features, protocols/guidelines and a workflow engine.

Although I have yet to see mature products in the marketplace, components are evolving that will fundamentally change the way we deliver care.

People know that I have been very transparent about my own medical history, as described in this Politico editorial.

Here’s how I’m using Patient Generated Healthcare Data in my own care management activities.

For the past 15 years, I’ve had a supraventricular tachycardia (SVT) - an AV nodal reentry issue.    My resting heart rate is 45-50 beats per minute.   On hot days, after I’ve eaten, my heart rate leaps to 170 beats per minute if I exercise vigorously then suddenly stop.     I perform a Valsalva Maneuver  and within a few minutes, my heart rate returns to normal.

I’ve never had any lasting consequences from this SVT.    I could take beta blockers, have an ablation of the ectopic pacemaker in my heart, or just accept that a few times per year I’ll have an arrhythmia.    I’ve chosen the later.

We’ve attempted to capture an ECG of my arrhythmia, but have never been successful.  We’ve tried a stress test, a holter monitor, and other wearable approaches.   It occurs too infrequently to capture.

We now have a solution.   I have attached an AliveCor ECG monitor to my iPhone 6.   The next time I have symptoms, I’ll just hold my phone and capture a perfect Lead I ECG.    From my phone, I can send it after capture to my PCP and the BIDMC electrophysiology expert for review.    It will be reassuring to know that I do not have episodic atrial fibrillation or an unstable ventricular tachycardia.

The cost of this technology is $70 dollars.

Although my body mass index has been constant at 22 for the past 15 years and my caffeine free, low sodium, vegan diet has kept me healthy, my genome is finally catching up to me and I’m starting to experience the essential hypertension (systolic of 140-150) that has been present in generations of both sides of my family.    Diet, exercise, blood pressure monitoring, vitamin D (may be helpful), and salt restriction are reasonable first approaches.   If they fail, then thiazide diuretics, calcium channel blockers or ace inhibitors are the next step, presuming there is no underlying root cause to treat.

As part of my initial assessment, I’m using a Withings Wireless blood pressure monitor with my iPhone 6.

I’m taking readings when I first wake up, before/after the Massachusetts Turnpike commute, at the end of the business day, and before bed.

Thus far, I’m seeing normal blood pressures on weekends after a day of farm work.  I’m seeing 140-150’s after the commute.   In case you’re not familiar with driving in Boston, it looks like this 

After a 12 hour day of meetings, I’ve seen a few spikes to 160, then a return to 130’s by bed time.

All of my measurements are uploaded automatically to the BIDMC electronic health record from my phone within 1 second.

The cost of this level of monitoring is $120.00

I also use a Withings Pulse to monitor my steps/elevation/distance/calories burned/pulse/pulse ox and a Withings Smart Body Analyzer to track my weight/body mass index.

All of this data is displayed with a variance analysis on my phone.

I’m not endorsing these products and have no financial relationship with either AliveCor or Withings.   I’m simply describing my experience that an iPhone 6 can become a middleware hub for healthcare information, enabling me to be the steward of my own data and share it with a healthcare system/provider at minimal cost.

The devices are easy to use and there is end to end data integrity from point of origin (the measurement) to point of use (the doctor).  

It’s clear to me that patient wellness (rather than treating sickness) will require more objective and subjective (pain score, mobility, mood) data than we gather today.   EHRs are not yet optimized for incorporating these novel data sources, but the Care Management Medical Record used for team-based coordination of life time care, must leverage the power of new healthcare enabled mobile devices.

Unity Farm Journal - Second Week of July 2015

Living on the farm means that every day is an adventure.   As Forrest Gump said, “you never know what you’re going to get”.

Last Thursday evening, at midnight, the Great Pyrenees began to bark with a cadence and volume that indicated a serious problem.   The llama began to trumpet.   The guinea fowl began to "buckwheat" inside their coop.    The ducks and geese quacked and honked.

I grabbed a flashlight and ran out to the barnyard.   A pack of 12 coyotes was circling the alpaca paddock, howling at the top of their lungs.  There were old, adolescent and young coyotes all making menacing movements toward the alpaca.

The coyotes and I have a tenuous relationship.    Like other predators, I know they are the top of food chain and play a valuable role in the ecosystem.   I’m a vegan and do not want to kill/injure any living thing.

When a single coyote appears in the barnyard I chase it away (or the guineas gang up on it).    With a pack of 12, I was a little less sure of myself.    I immediately began yelling at the top of my lungs I broke a few thick branches across a tree trunk, making a very loud noise.     I do not own a firearm (although Kathy and I are licensed to do so), and recognized my options to defend the animals were limited.

I threw rocks at the trees/bushes in their general direction, further creating noise.  They backed off.

Did I know what I was doing?  No?  Was it the right thing?  Per WikiHow, I did everything right when encountering a coyote pack.

The coyotes have not returned and all the animals are safe.

Keeping predators away was important this week since we released our eight week old chickens into the barn yard to free range.   We released

3 Buff orpingtons
6 Barred rocks
2 Andalusian blues
2 Ameraucana
2 Cuckoo marans
2 Golden laced wyandottes

that we had been raising in our mini-coops from 1 day old chicks.

They are running all over the property (including a rest on the air conditioners) and each night have come safely home to the coop.

With the mini-coops empty, we moved the last of our baby chicks (Ameraucanas) to the mini-coops and we moved 7 pheasants to the chicken pen, where they will mature until they are 16 weeks old and we can release them to the forest.

The geese continue to patrol the property and act like watchdogs.  This week they learned to swim but they still aren’t sure what to do with running water (streams are scary)

The bees continue to make honey, capturing the last of the summer nectar from the wildflowers around the farm, including this grove of mint.

We’ve completed the picking of our strawberries raspberries, gooseberries, and early blueberries for the season.   The mid-blueberries should be picking next week and the late blueberries in August.

Our coursework at Umass is going well.  I’m learning a great deal about the role of temperature, humidity, ethylene, O2/CO2, and physical handling of vegetables post harvard.

As Kathy and I think about our strategic plan for the year, we’ve both agreed that we must be careful not to produce too much of any one commodity and find that farm life has become a burden instead of a joy.   We’re working on refining our daily routines, automating processes, reorganizing workflows, and thinking about the right tools that will simplify our tasks.    At the moment, I’m adding a 16 cubic foot trailer to the barnyard so that we can more easily haul manure to windrows in the orchard instead of composting thousands of pounds of manure for months then moving it in mass.   I’m considering another hoop house just to keep the farm equipment organized and out of the elements.  I’m refining the layout of the barnyard.  

Just as a hospital would re-engineer its business using toyota production techniques (LEAN, six sigma etc), we’re doing the same.   Who would have thought that engineering ideas would be so useful in an agricultural setting!

Trajectory not Position

In my various state, federal, and international roles I interact with a large number of policy makers from the executive and legislative branches of government.  I testify to them, write policy papers, and call their support staff frequently.

At the moment in our society,  there tends to be a general proclivity to be a criticizer rather than a doer, to tear down rather than build up, and to have hearings instead of taking individual action.

Everyone talks about what has not been done instead of examining the progress made.

A great deal of leadership time is spent defending the actions of the past, making promises for the future and filling the present with powerpoint instead of programming.

How do we break this cycle of negativity?

My view is that we must believe in incremental progress, communicate broadly, and focus on our trajectory not our position.

What do I mean?

Ten years ago when I chaired the Health Information Technology Standards Panel (HITSP), the debate focused on such topics as

Is your XML better than my XML? (CCD versus CCR)
Is your HL7 2.x implementation guide better than mine?
Should LOINC coding of labs be required?
Can clinicians code problem lists using SNOMED-CT?
Are electronic public health submissions even possible?

In 2015, none of these items are debated.  The dialog has shifted beyond controlled vocabularies to such topics as building trust fabrics across organizations, refining transition of care standards and embracing new architectures based on FHIR/OAuth/REST.

John Kotter taught us that all change requires a sense of urgency.   I agree that there is an urgency to improve healthcare IT usability, workflow, and functionality.    

However, there is no need to panic.     We are in the biplane era of healthcare IT.    Flying cars are better than biplanes but that does not imply we can widely deploy flying cars without inventing jet aircraft first.    There are logical steps from our current state to our future state.

When I testify, I listen intently to questions and commentary.    Often there is limited domain understanding of the nature of healthcare data, existing regulatory requirements, and clinical workflow.    Rarely is technology the rate limiting step to innovation - the challenges are policy, psychology, and culture.

At age 53,  my personal medical data is electronic.   That was not true when I was 43.

At age 22, my daughter has never encountered a paper based record as an adult.   She has always had access to 100% of her healthcare data on her iPhone.  That was certainly not the case for me.

Since 1996, our ability to respect patient privacy preferences has improved immensely.   See this twenty year review of HIPAA that illustrates how far we’ve come.

Some people call me overly optimistic.   I tell people I am even tempered and predictable.   I will neither over promise future progress nor use hyperbole to over simplify the complexity of the process issues involved in IT transformation.

I  look at the experience of three generations of my family.  The trajectory of IT over the past 10 years has been overwhelmingly positive.    The next 10 years will continue to improve data liquidity, patient access, and usability.

Let’s all be doers.    Our position will be imperfect because there will always be room for improvement.   However, looking back after years of effort I can say that our trajectory vanquished many IT dragons along the way.

Unity Farm Journal - First Week of July 2015

It’s a week for strategic planning.   Just as I wrote a basic draft framework for  FY16 BIDMC information systems, I’ve written a draft plan for the next year at Unity Farm.

Here’s our best thinking as of July 2015:

Unity Farm was founded on a few basic principles

1.  A complete environment that challenges us mentally and physically
2.  A nurturing place for animals and plants
3.  A place that enables us to pursue a life focused on sustainability
4.  A place to reduce and optimize belongings
5.  A place for generations to gather

It is meant to be a labor of love, not a profit center or large supplier of any one commodity.   It will be diverse, experimental, and manageable without requiring a permanent staff.

The Living Things

Alpaca/Llama - we have the barn facilities for housing no more than 14 camelids i.e. 5 male alpaca, 8 female alpaca, and 1 llama.   Our breeding program will be limited to keeping the herd vital.  We will not breed camelids for sale.

Dogs - the Great Pyrenees dogs are our companions and have successfully kept predator losses to a minimum.    Recognizing that their lifespan may not exceed 10 years, we’ll have to plan for replacement/possible overlap of young/old but will only keep two dogs at steady state.   We will not breed dogs for sale.

Cats - the cats keep our indoor rodent population under control and provide a vibrant presence inside the house.

Ducks - we have the facilities for housing no more than 12 water birds.   They provide eggs, fertilizer, and insect/slug control.   We will not breed ducks for sale.

Geese - we have the facilities for housing no more than 12 water birds.   They eat weeds and guard the barnyard against predators.    We will not breed geese for sale.

Chickens - we have the facilities for housing no more than 100 land birds.   They provide eggs, fertilizer, and insect control.   We will not breed chickens for sale

Guinea Fowl -  we have the facilities for housing no more than 100 land birds.  They provide tick control and guard the barnyard against predators.    We will only sell guinea fowl when the population exceeds 60 birds.

Pheasants - we have a property size that can accommodate 6 pheasants.   They will be released at maturity and propagate in the forest as nature allows.

Bees - we have the nectar sources that can accommodate 12 hives.   We will maintain 22 hives by keeping bees at multiple local properties.

Pigs -  We have space for 2 pigs.  Pigs can efficiently process our fruit waste/pomace, vegetable waste, and edibles that would otherwise be composted.   We will not breed pigs for sale.   They would be companion animals.

Others - we will not add sheep, goats, horses, donkeys, or cows to Unity Farm.

The Products

Vegetables - We’ll grow four seasons of vegetables in the hoop house for Unity farm friends/family and creatures.  We will not sell fresh vegetables.

Orchard - We’ll grow apples, stone fruits and berries for Unity farm friends/family.  We will sell not run a U-pick.

Mushrooms - We’ll grow Shitake, Agaricus, Winecap, Nameko, Oyster, Lion’s Mane, and Ganoderma for Unity farm friends/family.  We will sell Shitake.

Cider and beer - We’ll make hard cider and beer for Unity farm friends/family.  We will sell cider.

Honey - We’ll make honey and wax products for Unity farm friends/family.  We will sell honey and wax.

Mead - We’ll make mead for Unity farm friends/family.  We will sell mead.

Eggs - We’ll have eggs for Unity farm friends/family and sell eggs.

Fiber - We’ll harvest fiber yearly and sell yarn.

Permaculture - We’ll experiment with paw-paw, ginseng, and other produce to determine what works in our environment.

Goals for next year

1.  Coursework in the UMass Sustainable Food and Farming Certificate Program
2.  Raise 21 young chickens, 3 geese and 6 pheasants
3.  Try permaculture experiments  (paw paw, ginseng, rice, sun choke)
4.  Refine cider, mead and beer recipes
5.  Raise our young alpaca
6.  Build up our 22 hives for winter
7.  Evaluate the best use of our remaining barnyard space - build a pig enclosure or an equipment barn
8.  Grow vegetables, fruits, and mushrooms
9.  Process our alpaca fiber
10.  Maintain woodland and trails

Creating the FY16 BIDMC IS Strategic Plan

I recently wrote about the process of setting FY16 Clinical Information System Priorities for the next year.   That project is proceeding well and in parallel I’ve created my own contribution.   I do not want to  influence the stakeholder consensus at all, but members of the IS Governance committee asked for my opinion.

Here’s my thinking:

Background

Each year, BIDMC Information Systems works with business owners to support BIDMC annual goals with information technology tactics.  This ensures that the mission of BIDMC is supported by suitable operational tools.   From 2012-2015, all hospitals in the US were compelled to focus their attention on Meaningful Use, ICD-10, the HIPAA Omnibus Rule, and the Affordable Care Act.  Since those projects are nearly completed, it is important for BIDMC stakeholders to enumerate the new technology priorities which will best support their activities in the coming year.

In the past, input of all stakeholders was gathered and assembled into a plan.   Given the increasing complexity of quality, safety, and regulatory demands shaping the behavior of hospitals and professionals, it is important that a standard framework with benchmarking and gap analysis be used in strategic planning, adding maturity and formality to the process.

The Framework

Specific industry frameworks exist today that apply to the different divisions of information systems.   For security, BIDMC has chosen the NIST 800 framework to support yearly security audits, gap analyses and strategic planning.   For clinical functionality, the Health Information Management Systems Society (HIMSS) Electronic Medical Record Adoption Model (EMRAM) provides industry standard, frequently updated benchmarks.   For infrastructure, the Information Technology Infrastructure Library, is a set of practices for IT service management.   For financial systems (enterprise resource planning and revenue cycle), best practices are documented by industry analyst firms such as Gartner as well as software vendors.

The Process

For FY16, we convened stakeholders in June and July to examine the current state of BIDMC applications and infrastructure using the appropriate framework tool for each domain.    In August, we will document the gaps and clustered projects into 15 specific areas for action.

My input

1.  Continue to self build the core inpatient, outpatient and ED systems of BIDMC for at least 5 years until the market for cloud hosted, mobile friendly, population health focused commercial EHRs matures.  Today at BIDMC, inpatient clinical documentation is a hybrid model of paper and electronic documentation.   This includes nursing. notes,  vital signs/flowsheets, and care plans.   It also includes physician daily progress notes, operative notes, history & physicals, consult notes and discharge summaries.   In FY16 we will implement structured and unstructured clinical documentation for these functions  to 50% of the ward beds.   We will complete the rollout in FY17.

2.  Today, the owned BIDMC community hospitals use 3 different installations of Meditech with different configurations.   We will migrate all owned BIDMC community hospitals to a cloud hosted version of Meditech with a single record per patient, implementing in FY16 for a go live in FY17.

3.  Today,  BIDMC community ambulatory practices use multiple different medical record systems.   We will migrate BIDMC community ambulatory practices to the smallest reasonable number of ambulatory solutions in FY16 and FY17.

4.  Today, BIDMC uses an older PACS system that no longer meets business needs.  We will replace our PACS FY16 and FY17.

5.  Today, the laboratory instruments at BIDMC are approaching end of life.   We will focus on lab analyzer replacement in FY16

6.  Today, there are gaps in interoperability among the owned and non-owned affiliates.   We will continue our phased implementation of interoperability, ensuring every affiliate has the appropriate data sharing (push, pull, view) necessary for the level of clinical integration required in FY16 and FY17.   We will also share email directories in FY16.

7.  Today, patient generated healthcare data is manually entered in applications and websites.  We will better engage patients and families using mobile technologies and automated data capture including the BIDMC@Home app in FY16 and FY17.

8.  Today, interaction among staff is limited to email, windows file sharing, and the web portal.  We will enhance staff communication using internally hosted social media technologies including secure texting, groupware collaboration, and cloud-based file sharing in FY16 and FY17.

9.  Today, we have largely remediated our applications for ICD-10 in anticipation of an October 1, 2015 go live.  In FY16 we will support the ICD-10 go live and ongoing optimization

10. Today we have attested to Meaningful Use Stage 2, but will have to attest again in FY16 and FY17.  We will not focus on Meaningful Use Stage 3 until its requirements are clarified in a final rule.

11. Today, we have a robust security program with 14 work streams.   We will continue to follow the NIST 800 framework and respond to emerging new security threats in FY16 and FY17.

12. Today, we submit our ambulatory and hospital data to the Massachusetts eHealth Collaborative Quality Data Center for computation of pay for performance, accountable care, and benchmarking measures.   We will continue to support this process for emerging new measures.

13. Today, we run an older version of Peoplesoft.   We will upgrade to the most current version and attempt to retire as many third party add ins/customizations as possible in FY16 and FY17.

14. Today, our owned community hospitals support their own networks, active directory and email.   We will consolidate networks, active directory, and email with BIDMC in a phased, incremental manner that takes into account budgets, competing priorities, and business cases.

15. We will continue to refine our disaster recovery capabilities using a combination of public cloud, private cloud, and multi-data center redundancy.

Unity Farm Journal - Fifth Week of June 2015

I sometimes joke with my daughter that I finished 25th grade, doing 2 bachelor’s degrees, 2 masters degrees, an MD, and a fellowship.   As a Harvard Professor, you’d think I would be done with sitting on the student side of the room.

Last year Kathy and I completed Bee-school (not Harvard, Wharton or Sloan B-school) at the Norfolk Agricultural School

For the next year, we’re enrolled in the 15 credit UMass Sustainable Food and Farming Certificate Program, an online/evening curriculum.    The core course is  Organic Vegetable Production (3 units).   We’ll also be taking Backyard Homesteading (3 units), Introduction to Permaculture  (3 units), Farm planning, marketing, and management (3 units) and Post Harvest Handling  (3 units).

Life is about continuous learning and with each passing year we are polishing our  life skills.

We can now make near perfect hard cider, mead, and honey lager.

We can raise numerous mushroom species from spore to farmer’s market.

We can keep 100 animals happy and healthy, protected from predators while free ranging over 15 acres.

However, we still have much to learn about packaging, preserving, and marketing farm goods.  I look forward to the year of classwork ahead.   We'll fill the time previously allocated to House of Cards and Game of Thrones.

The Summer continues to be a busy time on the farm with planting, harvesting, and maintenance activities still continuing at full tilt.

We’ve planted more peppers, eggplant and tomatoes.   We’re harvesting peas, carrots, strawberries, raspberries, and blueberries this week.   We’ll plant daikon radish, standard radish, chard, lettuce, and spinach this weekend for early Fall harvesting.

We kegged our honey lager this week and racked our mead.    Honey production is ramping up and we extracted 25 pounds of honey over the weekend.   If we’re lucky, we could bottle 500 pounds of honey this year.  Each 10 gallon batch of mead takes 35 pounds.   We age our mead for a year, so watch for it on the Unity Farm Store website next year.   Next week we’ll brew a summer wheat beer.

We dried 100 pounds of  fresh Shitakes (which became 20 pounds of dried mushrooms).  Not only does drying preserve the mushrooms for several years, it concentrates the flavor.  A rehydrated dried mushroom makes better mushroom soup than a fresh one.

Our new baby alpaca continues to thrive.    Mom is very protective and hums whenever he leaves the barn to play with the other alpaca.

This week, we’ll set the geese free to  range in the forest.   They are now fully feathered, nearly full grown, and have acclimated to the idea that the duck pen is home.

We’ve decided, based on the advice of experts, to free range the pheasants in the Fall, once they are older and stronger.

We continue to harvest guinea eggs from all over the property, hopefully reducing the fecundity of our growing guinea population.

I’ve trimmed and re-cut all our trails.  The burst of summer growth, especially vines, has narrowed all our paths.   They’re now back to their original 6 foot wide design.

And yes, on July 4 we’ve committed to sitting under the pergola, sipping a honey lager, and watching the clouds roll by.   As Kathy says, if there is a time when we sit down, we’ll be sure to memorialize it with a picture!

Managing Up

I took my first job at age 13, building model planes and skateboards at Palos Verdes Hobby Shop. Over the past 40 years, I’ve reported to over a dozen people.   Some were inspirational and charismatic.   Others were more task delegation oriented.   Some were problem solvers.  Others shunned detail.    Some were great listeners.   Others were talkers.

Every leader is different and working for them requires an understanding of their preferences.   Although I’ve never “managed up”, I have adapted to the needs of the various people I’ve worked for.

Here’s my advice on thriving in complex hierarchical organizations.

1.   Assess your peers and your superiors frequently.   Imagine yourself on a balcony watching the people in your organization as if you were watching a play.   Understand the self interest of each character.   Just as personalities would be described in a work of fiction, you’ll see the self-interested careerist, the  servant leader, the manipulator, the fair weather friend, and the person you’d want in your foxhole during battle.  

2.  When you run a meeting, play to the characteristics of each person you have assessed.   If someone does not like details, do not ask them to be on a task force to write the plan, ask them to serve on the steering committee to approve the plan.  If someone wants to avoid blame at all cost, shield them from any direct responsibility for the project.   If someone needs credit to reinforce their ego, give credit liberally.   Keep in mind - “Success has many fathers, failure is an orphan” and “It is amazing what you can accomplish if you do not care who gets the credit.”

3.  Determine the information flow needs of your superior.   Does the person want a detailed progress report with an honest assessment of delays and goals not met?  Does the person want a single high level powerpoint slide with green, yellow, red?   Do they want any communication at all?   Will they offer to remove barriers/accelerate enablers, solving problems?   Will they shoot the messenger?   Based on the style of your superior you may produce an elegant project summary documenting progress or adopt a ‘don’t ask, don’t tell’ approach.

4.  CEOs last about 4 years.    This Harvard Business Review article describes the typical  pattern of a CEO transition.  If you find the leader of an organization hard to work for, you can leave, ignore the problem, or just wait them out.    Be careful of believing the grass is greener elsewhere.  As one wise person recently told me - “If you study the leadership of large, complex organizations you’ll find it’s the same clowns, different circus”

5.  Recognize that 10-20% of your work life will be spent on non-value added activities.   Your organization will likely have standing meetings that may not be relevant to your area, but your presence/visibility reinforces your place on the team.   Such meetings may feel like an interruption in your ability to do creative work, but maintaining a supportive environment for real achievement requires the buy in of your peers and superiors.   Convince yourself that investing 10-20% of your work time in the meetings required by your superiors will pay dividends over time.  And if you find a particular standing meeting to lack value, remember that with senior leadership turnover every 4-5 years, the meetings will change soon enough.

Life is short and none of us will have a gravestone that says “I managed up and lost 10-20% of my productivity”.   However, part of maturing as a leader is realizing that to accomplish the things you like, you have to actively manage the things you don’t like.    Managing up, adapting to your superiors and peers of the moment, is an advanced leadership skill.