Unity Farm Journal - Fourth Week of January 2016

We’ve passed the coldest part of winter and already our thoughts are focused on the germination of our Spring crops and planning for the growing season ahead.    This week I used the germination station, pictured below, which can produce 360 seedlings at a time using grow lights and heat pads, regardless of the external temperature.    Winter Density lettuce, Romaine, and Japanese Mibuna are now growing. In a few weeks I’ll put them in our newly prepared raised beds.   We’ll also be starting a few other lettuces next week

Bibb (Buttercrunch)
Boston (Nancy)
Greenhouse (Rex)
Red (Rex Cross)
Mache (Vit)

We’ve designed a monthly succession planting schedule to keep the germination flats and hoop house beds full (with crop rotation) all year long.

My Umass homework this week involved reading this article about Farming for Quality of Life Improvement and writing our personal story:

“My wife, daughter, father-in-law and I moved to Unity Farm in Sherborn, MA four years ago.   We had lived in Wellesley, MA for the previous 16 years.     When we originally moved to Wellesley, it was a family oriented place with many modest homes, many young children, and a rural downtown (Diehl’s hardware was the largest business).   Today. Wellesley is filled with exercise studios, Range Rovers, elegant shops, overworked parents, and few modest homes.

Exercise on the farm involves a shovel, not a personal trainer.   Entertainment is rolling in the hay with the pigs, not going shopping.   We have a small delivery van and a front loader, not a  Range Rover.    The amount of financial farm losses we experience every year is minor.

The farm enabled us to create a multi-generational household where everyone lives, works, and plays together.   Although my father-in-law passed away last year, it’s still a place where generations gather and my daughter will be married at the farm this Summer.

To paraphrase the  Visa card commercial - the price of feeding the pigs every year - a few hundred dollars.   The joy of feeding the pigs - priceless.”

We found fresh Bobcat tracks around the treehouse today.    A local television station captured a picture of one of the Unity Farm Bobcats last fall.

The freshly fallen snow looks like a freeway of coyote, bobcat, raccoon, fisher cat, turkey, deer, and fox tracks.

We’re expecting more snow tomorrow.   I’ve found the snowblower attachment for the tractor to be invaluable.  The pigs really do not like snow, so I put them in their barn and used the snowblower to clear their entire paddock during the last snowfall.   The geese do not like the snow since they tend to ski on their webbed feet.

Now that Unity Farm is fully operational, we have quite a rhythm.   Every creature - pig, goose, chicken, guinea, duck, alpaca, llama, dog, and cat has a routine and knows its place in the ecosystem.   Every plant has its season.   The land creates food, shelter, and water flow.   Everything fits together in unity, just as we hoped.

The Senate HELP Committee Draft Legislation

On January 20, Senators Alexander and Murray released the  Bipartisan Senate Health Committee Staff Draft of Bill to Help Improve Health Information Technology for Doctors & Their Patients

Here’s a summary

This is a really important bill.   Why?

It includes legislative changes that will help reshape/evolve Meaningful Use.

You may have seen the recent confusing press about Meaningful Use Stage 3.  CMS Administrator Andy Slavitt tweeted from JP Morgan that Meaningful Use as we know it will end since we’ve lost the hearts and minds of clinicians.

A few days later, Karen DeSalvo and Andy Slavitt posted this blog which suggested Meaningful Use Stage 3 is still in force.

What happened?

Here’s my opinion:

Andy Slavitt is outsider at CMS.  He was being was being very genuine when he said that Meaningful Use has run its course based on what he has heard from stakeholders.   However, there are folks at CMS who want the current path of Meaningful Use to continue.    Also, there are current laws on the books that make change difficult - ARRA/HITECH still applies to hospitals.

MACRA provides a path for eligible professionals to move from the highly prescriptive check boxing of Meaningful Use to  alternative payment models based on outcomes, but providing a path for hospitals requires new legislation.

The HELP Committee draft legislation may provide that path.

It requires HHS to reduce burden, a key point in revising the Meaningful Use construct.  It also enables data collection by a team of caregivers, and accelerates national infrastructure for provider directories and patient identifiers.

It forms a consolidated HIT Policy and Standards Committee, which is very reasonable.  
Policy and technology are two sides of the same coin.    Interoperability requires technology standards supported by governance and data use agreements.     In the past, the Policy Committee and the Standards Committee worked using a waterfall methodology - policies were created and then standards advice was requested.     The notion of one group, chartered to produce policy and technology in parallel, makes sense.

In some ways, the draft legislation echoes the standards harmonization work done by the Health Information Technology Standards Panel (HITSP), which I chaired from 2005-2009.     Here's the HITSP charter.

There is only one part of the draft legislation that I think is truly unhelpful - creating a government sponsored rating system  for healthcare information technology.    I cannot think of another industry in which the government provides the “Yelp”-like function.   A better approach is for private companies, such as KLAS to provide the research the market demands.   Last week, the combined HIT Standards and Policy Committees agreed by consensus that the government should NOT  develop and maintain a comparison tool, or expand the Certified Health IT Product List  to serve as a comparison tool.

I will watch this draft bill very closely.    I’m hopeful that Congress will give Andy Slavitt the support he needs to end Meaningful Use as we know it.

Unity Farm Journal- Third Week of January 2016

The farm is covered with snow and it’s 10F.   The yearly 3rd week of January chill has arrived.   The chickens and guineas are roosted in the warm coop.  The ducks and geese are wearing their down jackets, swimming and pretending it’s balmy.   The alpaca are cushed to the ground to avoid the wind chill.  The pigs are asleep in their blankets on hay covered beds in the pig barn.  Who knew that “pig in a blanket” describes a real behavior.   They’ve not yet asked for sheets (remember Orwell’s Animal Farm)

As a first step in my University of Massachusetts Farm Planning, Marketing and Management course, we were asked to formulate our goals based on identifying life priorities from a long list of possibilities.    Here’s my top 5 priorities ranked in order

Family Happiness
Health                      
Collaboration
Intellectual Stimulation    
Freedom/Economic security    

Using these priorities, we were asked to create a personal goal statement.   Here’s mine:

“To focus on family life while maintaining health and serving the community,  constantly learning/experimenting and having the time/economic freedom to continuously improve life processes.    The daily and seasonal rhythm of Unity Farm is the base of operations for all these activities.”

This is complementary to the farm goal statement I developed in 2015 as part of my Backyard Homesteading course.

“Unity Farm provides organic fruits and vegetables for the family and the local community. We have used  sustainable agriculture principles to empower the daily and seasonal rhythm of supporting the plants and animals. We have nurtured the property to be a healthier ecosystem than it has ever been.”

In the next few weeks, we’ll select the farming enterprises we want to pursue based on our personal goals, then develop a formal business plan.   Possible enterprises to model at Unity Farm include

Livestock
Bees (pollinators, queen rearing, honey, mead, honey lager beer)
Guinea fowl (tick control)
Chickens (eggs)
Ducks (eggs)
Earthworms
Geese (watchdogs, weeding)
Llamas/alpacas (fiber)

Forestry
Fuel wood
Fruit trees including fruit products such as Hard Cider
Nut trees
Blueberries
Strawberries
Cane Berries (blackberries, raspberries, etc.)
Grapes

Vegetable Crops
Asparagus
Beans - Jacob’s cattle
Beets - Chioggia and Gold
Broccoli -Belstar
Brussels Sprouts - Doric
Carrots -  Napoli
Cucumber - H19
Eggplant - Littlefinger
Kale - Meadowlark
Lettuce - Winter Density
Peas - Sugar Pod
Peppers - Shishito, Jalapeno
Pumpkin
Spinach - Bloomsdale
Squash - Kabocha, Zucchini
Turnips - Haruke
Tomatoes - Roma

Mushrooms - Shiitake, Oyster, Nameko, Gandoderma, Winecap

Workshops such as llama care, mushroom cultivation, and cider making

One of our most popular products at the moment is the Unity Farm Honey Lager - a 7% beer with 11 pounds of honey per keg and Cascade hops.    We provide the honey but in the past we’ve purchased the hops.   We’ll begin growing our own hops this Spring in the new 12x20 foot hopyard I designed based on the experience of Smith Rock Hop Farm and the engineering techniques I learned while building the zip line.  I placed 15 feet posts, attached 5/16 aircraft cable at the top running east/west and attached 3/16 aircraft cable at the top and bottom running north/south.  We’ll plant Cascade hops  4 feet on center and  on jute tied diagonally between the 3/16 cables.   We’ll expect a reasonable yield in our second and third years after planting.

It’s already time to start planning our 2016 germination schedule.   Warmth loving plants such as peppers, eggplant, tomatoes, cucumbers and broccoli are germinated a month before planting.    How do you germinate seeds in cold winter?   By heating them.  There are two basic kinds of heating pads
1)  the Hydrofarm which is low wattage and meant for indoor use.  It heats a standard seedling tray about 10-20F  above ambient temperature.  Thermostats are optional
2)  the Redi-Heat which is higher wattage and can heat a tray to 120F.  Thermostats are required.

Standard seedling trays are 11x21 inches and the potting bench I built in the hoop house is 22 inches wide.   We’ve placed a 5 foot Redi-Heat pad on the bench, then placed 5 seedling trays in 5 leakproof trays on top of it.

Each seedling tray can hold 72 1.5 inch blocks of soil in a 6x12 pattern.   You may not be familiar with soil blocking, but it’s common in Europe.   The idea is that you mix 3 parts peat, 2 parts vermiculite, and 2 parts compost with water to form a paste.   Using a soil block tool you create a perfect environment for germination.   Blocks are placed directly into the ground after sprouting using tongs.

This year, our project plan for germinating, planting and harvesting is aligned with the temperatures we’ve experienced in the hoop house, our crop rotation schedule, and succession planting - cold weather vegetables planted in beds that will be occupied by warm weather vegetables.  We’ll be able to get 2-3 yearly harvests from each bed using 4 season gardening techniques.    I try to adopt the best techniques from multiple authors, but for winter New England vegetable growing in hoop houses, there is no better resource than Eliot Coleman’s Four Season Farm

The planting begins soon!

Passing the Baton

After 10 years of work, today I passed the baton of leadership for US standards harmonization efforts to Arien Malec and Lisa Gallagher.   Here’s  a brief synopsis of the journey.

In 2005, Fran Schrotter, COO of ANSI, met with me in my Harvard office and asked if I would be willing to spend a few hours per YEAR chairing the Healthcare Information Technology Standards Panel (HITSP), a public/private partnership run by ANSI at the request of the federal government.   I agreed and within a few months, standards harmonization became a multi-hour per DAY commitment.

HITSP convened many stakeholders and worked directly with the Secretary of Health and Human Services, Michael Leavitt, via the American Health Information Community (AHIC).   Controversies at the time included the integration of the Continuity of Care Record (CCR) with the HL7 Clinical Document Architecture (CDA) to create the Continuity of Care Document (CCD/C32), debates about the right terminology for problems/medications/allergies, and selection of structured lab data reporting implementation guides.   Standards were harmonized and progress was made, but much work was left to do.

HITSP ended when the Obama administration began and was replaced by the Health IT Standards Committee (HITSC), a Federal Advisory Committee.  I became co-chair with Jon Perlin and the committee was populated with a diverse group of stakeholders, many of whom had served HITSP.    Controversies included the refinement of document content standards (CCDA), the broad implementation of vocabularies (Value Set Authority Center), and the decision to use SMTP/SOAP (Direct) as transport.   In 2015, the movement to FHIR, REST and OAuth/OpenID accelerated.   Government driven regulatory change began to shift to private sector driven innovation.   Much work is left to do.

What advice can I offer to Arien and Lisa?

As I handed actual running batons to them, here’s what I said:

Welcome to the leadership of the HIT Standards Committee.   You now have the privilege of facilitating the harmonization of standards nationwide.    Everything you say and write will be deemed influential.   You will aggregate karma - some good, some bad .  You will receive credit for things you did not do, while also receiving blame for issues you had little to with.

Just as in my days running track, my task has not been to win this race, but to avoid slowing down those who come after me.

Godspeed!

It has been an honor to serve.

The Future of Meaningful Use Stage 3

This morning, thirty-one healthcare organizations sent the following letter to HHS Secretary Sylvia Burwell.   Given the recent comments of CMS Acting Administrator Andy Slavitt at the J.P. Morgan Annual Health Care Conference, we remain optimistic.

-------

January 14, 2016
The Honorable Sylvia Burwell
Secretary
Department of Health and Human Services
200 Independence Ave., S.W.
Washington, DC 20201

Dear Secretary Burwell:

On behalf of the undersigned organizations, we are writing to express our concerns with the Meaningful Use (MU) program and the current state of electronic health records (EHRs). We recognize that the MU program has successfully driven the adoption of EHRs, with over 80 percent of hospitals and physicians now using these systems. We must now turn our attention to ensuring that all of the practices in our respective communities have high-functioning technology to achieve interoperability across all care settings. Yet, with the release of Stage 3, we fear the current trajectory of the MU program will hinder efforts to move forward.

Our collective experience with MU has shown that the current measures and pass-fail approach deter participation. In particular, the MU program has diverted clinician, staff, and other resources away from activities with greater patient benefit and has forced technology to develop in a way that limits innovation. The MU Modifications rule addressed these concerns by reducing some of the pressure physicians and hospitals face in trying to meet MU program requirements. These modifications, however, should not be looked at as a cure but as temporary relief while we work to restructure the MU program to fit future care needs and focus on improving interoperability and usability.

Despite the written comments of numerous stakeholders and data on provider experience with Stage 2 of the program, Stage 3 continues to press forward with the current, ineffectual Meaningful Use structure—the one-size-fits-all approach that lacks accommodations for the different needs of our practices and our patients. The Stage 3 final rule, like its predecessor rules, is too focused on pass-fail requirements and lacks emphasis on outcomes. By maintaining this flawed structure, we do not believe Stage 3 will support movement towards more innovative care models or encourage continued participation.

Stage 3 also fails to prioritize foundational issues to improve interoperability, which is imperative for our medical communities to function at their highest levels. By using MU as an enforcement tool, there has been little improvement in data exchange. Many in our communities are facing excessive costs to purchase EHR interfaces and upgrades, which only support limited interoperability. Patient medical information is also shoehorned into a format that was designed for MU measures, and not in a way that accommodates the needs of physicians and patients. Addressing these issues must be a priority, but what is required in the Stage 3 rule limits progress while diverting needed resources. Regrettably, we believe the Stage 3 final rule maintains the same problematic measures in Stage 2 and will not put the nation on a path to reach these goals.

Lastly, the MU program has been the driving factor behind the design of EHR technology. Health IT vendors routinely state that meeting MU requirements monopolizes most of their development and testing time and that many of the upgrades or features most requested by their customers are put on the backburner until the complex process of certifying for MU takes place. We believe Stage 2 EHR design requirements have been a fundamental drag on interoperability and that Stage 3 will worsen these problems.

Given the above concerns, we urge you to reconsider Stage 3 and refocus the Administration’s efforts on the infrastructure needed to promote adoption, enhance interoperability and improve usability. We are of the collective mindset that this is an opportunity to improve the current trajectory of EHRs and the MU program to best support technical innovations and outcomes-based care. Navigating the digital landscape is a constant learning process. As health care providers who are at the forefront of incorporating these digital health tools, we appreciate the opportunity to share our thoughts on a path forward for the MU program.

Sincerely,

Advocate Health Care, IL
Aurora Health Care, WI
Austin Regional Clinic, TX
Baptist Health, KY
Baylor Scott & White, TX
Beth Israel Deaconess Medical Center, MA
Billings Clinic, MT
Boston Children’s Hospital, MA
Collaborative Health Partners of Virginia and Central Virginia Family Physicians, VA Confluence Health, WA
Cornerstone Healthcare, NC
Crystal Run Healthcare, NY
Dreyer Clinic, IL
Eastern Virginia Medical School Medical Group, VA
EmCare, TX
Emory Healthcare, GA
Fairview Health Services, MN
Geisinger Health System, PA
Henry Ford Health System, MI
InterMed, ME
Intermountain Healthcare, UT
The Iowa Clinic, IA
Marshfield Clinic Health System, WI
Mount Auburn IPA, MA
Partners HealthCare, MA
TEAMHealth, Inc., TN
Trinity Health—New England, CT
UMass Memorial Health Care, MA
University of South Florida Health, FL
Vanderbilt University Medical Center, TN
Weill Cornell Medicine, NY

Unity Farm Journal - Second Week of January 2016

I’ve finished the University of Massachusetts winter semester and submitted my final homestead map - pictured below.

It contains:

*Woodshed - store 8 cords of wood for heating
*Storage Barn - 20x24 structure for equipment
*Animal Housing which includes workshop - small barns for alpaca, llama, dogs and pigs providing weather protection, hay storage, and workshop
*Roof Catchment with cisterns - keyline design which results in water flow from gutters into the swales which irrigates cropland and feeds the vernal pond. A cistern under the front house gutter could store 900 gallons of water (based on the available space in that area)
*Cart Paths and Lanes - 1.5 miles of paths, some dating to the Revolutionary War which provide access to all agricultural and water features
*Contour Planting - sunchokes and ginseng in the understory of our forests using the partial shade on hillsides to produce crops
*Ponds and Dams with Swales and Terraces - Water management is an inter-related connection of house, land/hardscaping, streams, ponds and wetland.
*South Facing Outdoors - bee yard and all animal housing is south facing to capture
solar heat
*Greenhouse - 3 season food growth (with some winter production of lettuce/spinach/
chard)
*Food storage and  root cellar - storage for our canned/preserved foods and
onions/potatoes/squash to provide calories over the winter
*Wetland Water Cells - to absorb winter snow melt and heavy rains/prevent erosion
*Small Paddocks - for llama/alpaca, dogs, pigs
*Patch gardens - Herb Spiral near the kitchen to provide a convenient cutting garden,
perennial food crop planting throughout the property , mushroom logs
*Fertility Crops and Mulch and Compost - clover/legumes are grown as part of
polyculture in the orchard. Soil is amended by sources of manure and decaying mushroom logs

My Spring course is 13 weeks of farm marketing and management.   I’ve always said that you can make a small fortune in farming, as long as you start with a large fortune.   We’ll see.

Now that the weather has turned cold and wet, it’s time for indoor maintenance work such as sharpening tools, organizing, and streamlining.    I rebuilt 5 kegs by replacing all their gaskets, set up a bottling/label gluing area in the cider house, and re-organized all the cider and lager plumbing to make it easier to serve our hand crafted beverages.     Here’s a view of the re-built kegs and the new Unity Farm label.

We’ve divided the pig paddock into two half acre portions so that we have free area for letting the dogs run, isolating a sick animal or stacking snow if we have no other place to put it.   The pigs are very happy in their south facing sunny barn with a half acre of grass.   They come when called, recognize our faces, and are incredibly affectionate.    I realize that it is important in any herd to show the leadership of humans.    Here’s Tofu, standing on my chest, eating my nose.    Who is dominating whom?

Unity Farm Journal - First Week of January 2016

The citizens of Unity Farm have experienced a deep freeze this week - nightly temperatures in the single digits.   How have they fared?

The geese and ducks have a heated house but choose to stay outside - those down jackets they are wearing have done a good job.  No signs of frostbite on their bills or feet.

The chickens and guinea fowl have a heated coop and every bird has been roosting near the sources of warmth.   Tyrion, our bantam rooster has slight frostbite at the rear of his comb from the time he spends outside of the coop during the day with the hens.   Swayze, our buff orpington rooster, also has a few discolorations on his comb.    Otherwise, every bird has done well through the cold.

The alpaca and llama have stayed close to the ground to avoid wind chill and to soak up the biological warmth of decomposing hay.

The pigs really do not like the cold and have been nesting deep in hay bales, under blankets, next to their heaters.   Although they wag their tails while grazing in the sun on 20 degree days, as the shadows of night approach they squeal and run for warmth.

Hazel and Tofu, our new pigs, are now best buddies.   We’ve removed the dog barriers we used to separate them during acclimation.   They eat, sleep and play together in the pasture all day.     Both enjoy their belly rubs. come when called, and look forward to visits from their humans.    In some ways, pigs are more social than dogs and really want to spend time with us.   They are good, good pigs.   Photos below

The rain, snow, and freezing temperatures have made the alpaca paddocks an icy, muddy mess.   I thought the issue was poor drainage due to compacted soil but the issue was our last hay delivery.  The alfalfa bales, although eaten completely by horses , are only nibbled by alpaca, creating enormous piles of chaff.    That chaff accumulates on the ground and absorbs water, creating a foot thick sponge of composting alfalfa stems.   Over the weekend, I spent 6 hours with a pitchfork removing 18 wheelbarrow loads of alfalfa from the paddocks.

We finished up the tree house and two observation platforms last weekend.   All the safety features are now installed and family members feel much more comfortable with railings, hang grips, and benches in place.   The next step is the tree house roof to minimize snow accumulation.

With the coldest weeks of winter approaching, I’m spending more time indoors.   I reorganized the farm library, sorting it by animal and plant type for easy access.  I’ve cleaned and replaced all the gaskets on the cider/winemaking/beer equipment.    I’ll be brewing winter celebration ale next week.

There’s something special about reading next to a roaring fire on a cold winter night.  I’ve been reviewing selections from the permaculture literature to help me with the homestead design I’m doing as part of my University of Massachusetts coursework.    This week’s assignment was to analyze the food we consume every year and determine the layout of farmland necessary to grow it.  Here’s my analysis

We determined that it is possible to grow 100% of our yearly food at the farm, although we will still be dependent on the community  around us for supplies such as seeds, tools and electricity.  

The weekend ahead will be filled with freezing rain, so after I care for the animals and plants, I’ll be putting away the final holiday decor and catching up on my writing - a few book prefaces and my winter semester  final homestead design project.    The third week of January generally brings -10 to -15 temperatures on the farm.    We’re getting ready to hibernate.

Keeping Your Equanimity in 2016

2016 is a year when CIOs will feel even more overwhelmed than last year - demand will exceed supply (no matter what your budget), the pressure to deliver faster/cheaper/better will accelerate, and security concerns will dominate the agenda.   I’ve been asked how I maintain my equanimity given all that is going on.

Every year I refine the guiding principles that keep my life in order.   Here’s the 2016 edition:

1.  Minimize lost time - There are 168 hours in a week and I must use them wisely.   Commuting time in cars and planes is not very efficient.   How many meetings do we attend every year in person that could be done equally well by conference call or webinar?  Sure, there are some meetings that require in person contact to build trust or resolve a controversy, but many standing meetings, especially those which are largely presentation-based, can be done without the commute and parking hassles so common in today’s metropolitan areas.   Similarly, what is the time cost of a flight in the modern era?    An hour commute to the airport, arrival 1.5 hours before the flight so that you can navigate security lines and baggage handling, then waiting for the inevitable 1 hour flight delay that translates into commuting heroics upon arrival to get your meeting on time.   An entire day can be lost flying to and from a one hour presentation.    In 2016, I will minimize lost time by opening a new community-based IT office for my staff working on projects in suburban areas.   That new facility will be filled with  swing spaces and ad hoc meeting rooms that provide infrastructure to those who do not physically need to be in a downtown location.    Teleconferencing and virtual presentations will be encouraged.    Although I must be in Boston 2 days a week for such things as in person Board meetings, I will work in the new community office 3 days a week, eliminating about 10 hours per week of unproductive car time.    Similarly, I will limit air travel to impactful events - meetings with industry, government or academic leaders in a forum where discussion, rather than pure presentation, requires a personal presence.    I hope to reduce my time in airports by at least 10 hours a month in 2016.

2.  Do satisfying work each day  - I’ve written previously that there is no difference between my job and my life.   It’s not as if I’m an IT professional 9am-5pm then hand off the responsibilities to someone else.     All I can ask for is having a legacy of past activities that I feel good about, having satisfying work each day, and looking forward to future challenges.  In 2016 my international work will focus on (in alphabetical order) Canada/China/Japan/New Zealand/UK where I’ll do policy and technology education for government leaders.   My US national work will focus on writing about the challenges and opportunities facing the new president.    My regional/local work will focus on innovation projects such as embracing the internet of things, patient/family engagement, and advanced analytics in the BIDMC Health System.

3.  Family comes first - My family is also a continuous responsibility.   I am a father/husband/son 24x7x365.    In 2016 I will help my daughter (who is getting married in May) establish a self reliant future.   I will help my wife with fulfilling activities supported by the tools and infrastructure she needs.  I will help my mother with fulfilling activities in a stress free living environment (her one story home in California which I maintain).

4.  Be well - My personal physical and mental health directly impacts my ability to be productive.   I will continue to be a decaffeinated, substance free, vegan and get my daily exercise from the rhythm of running a farm with 150 animals and 15 acres of agriculture.   In my professional and personal lives I will continuously improve life processes to reduce anxiety/stress while also engaging in constant learning and experimentation such as the University of Massachusetts Sustainable Food and Farming certificate program.

5.  It takes a village - we often hear about the impending collapse of modern society and the need to become self sufficient.   I do not believe in the concept of self sufficiency.  I believe we need to work together as a community to maximize our self reliance, recognizing our dependence on each other.    I may grow 50% of my food, but I still need others in the community to supply the seeds, the tools, and the electricity I use in the process.  The same thing can be said of healthcare.  There is no way for a clinician to enter 114 structured data items per encounter of which 71 are user-documented (at BIDMC) in support of Meaningful Use, Quality Measures, and Alternative Payment Models.   We need a team of caregivers, IT professionals, and patients to gather the data needed to maximize safety, quality, and efficiency.   The only way any of us can get through the day is to spread the strain in a thin layer over many people.

If I can meet the needs of my professional life with a lot of help from my friends, help my family achieve their goals, and end each day with my physical and mental agility intact, equanimity will follow.

May all of you keep your optimism and your livers intact in 2016 despite the challenges.