Unity Farm Journal - First Week of April 2016

Our Spring projects are approaching completion just as the warm weather is about to return to winter.   Over the weekend it will snow and on Monday it will be 16F.

We’ve finished the new paddock, so now we have two pig areas

The Summer Swine Cottage , in the shade of pines with breezes coming off the drumlin.  It has a generous mud hole for wallowing

The Winter Pig Palace, facing south for maximum solar warmth.

In the next few weeks, I’ll move our mushroom cultivation shade house, which is no longer used since our mushroom logs are fully mature, to the summer pig paddock so they will have a 30 foot x 12 foot shaded area.    Hazel and Tofu are so smart and so social that they demand to be massaged, fed, and wrapped in blankets every every night.    Eating a pig is like eating a dolphin or chimp.  It’s hard to imagine how humans ever decided that killing a highly intelligent social animal for food was a good idea.

We’ve finished the blueberry netting on our early and mid blueberries.   We ran out of netting material and the late blueberries will have to wait until the next batch arrives in May.    We now have 3 dimensional coverage for 180 high bush blueberries and our gooseberries.   We planted them 3 years ago and so our crop this year should be very robust.

Unity Farm Honey Lager is one of our most popular products.   It’s made with 11 pounds of Unity Farm honey per keg.   However, we’ve had to buy the Cascade hops that combine with water, yeast, barley, and honey to create the amazing flavor.   Since we’re locavores, we really want produce the entire product on the farm and thus we’ve finished our first hops trellis.   In mid-April we’ll plant the Cascade hops rhizomes that will lead to enough hops two years from now for our Honey lager to be an all Massachusetts product.

We also bottled our Monastery Mead this week.   It's 14% alcohol, and made with all Unity Farm honey, water and herbs.

As a full Harvard professor, I’m required to spend 200 hours a year teaching.   This week, I drove the Umass Agriculture school in Amherst, Massachusetts to deliver a 2 hour presentation about mushroom toxicology, medicine, and mycoremediation (the elimination of environmental pollution with mushrooms).     It’s wonderful to experience the enthusiasm and energy of undergraduates who are in the early stages of forming their career goals.   Here’s the presentation I used.

This weekend will include more lettuce planting, mushroom log inoculation, trail clearing, and preparing for my next week in London, helping Dr. Bob Wachter advise the UK on national healthcare IT strategy.    I love London but look forward to a Summer in the paddocks instead of planes.

Evaluating Blockchain for Health Information Exchange

Yesterday, I read a New York Times article about a possible successor to Bitcoin called Ethereum, which provides a distributed database (no central repository) for the purpose of tracking financial transactions.

I immediately thought of the challenge we have turning silos of medical information into a linked, complete, accurate, secure,  lifetime medical record.  

Might blockchain technology be useful in healthcare?   I posted the question to my colleagues, Arien Malec (VP, Data Platform and Acquisition Tools at RelayHealth and the new Chair of the HIT Standards Committee) and David McCallie (SVP of Medical Informatics at Cerner)

Here is the dialog, reprinted with their permission.

John - Would a distributed database based on the blockchain idea b a way to aggregate health records?

Arien - Of course. But it dodges the hard part: network and business model.

David - I haven’t seen a compelling use-case for blockchain in healthcare yet, but I haven’t done a lot of digging.

I was impressed with a brief perusal of Ethereum.  They have build a blockchain “platform” that is de-coupled from the digital currency model.  Reportedly, a lot of companies are using Ethereum for internal projects – any place where you need to “move value around and represent the ownership of property” (as they put it.)

But even with their platform thinking, it still sounds a lot like money:

“This enables developers to create markets, store registries of debts or promises, move funds in accordance with instructions given long in the past (like a will or a futures contract) and many other things that have not been invented yet, all without a middle man or counterparty risk.”

So, go out there an invent those things….

Arien - In theory, one could use the blockchain to store health records and provide proof of provenance, etc.

But like this blockchain ridesharing company. there’s no compelling use case – that’s why I said the hard parts are network and business model.

To put another way: where are the anonymized drug markets for healthcare that drove Bitcoin?

David-  I think a blockchain might work as part of a decentralized “health record bank” (HRB) model where there was no centralization of authority or provenance for each consumer’s record.  Every time a provider makes a “deposit” to a patients HRB record, the deposit could be annotated and verified by the blockchain.  On presentation of the consumer’s aggregated record to another physician, the blockchain could be used to verify that nothing had been tampered with.  It might even be possible to verify that nothing had been excluded?  Not sure about that point.

The blockchain wouldn’t contain the record, but could be used to verify that the record and provenance were tamper-free.

Sort of an Uber-PHR.  Pun intended.

Arien - Yes, that’s exactly what I was describing. And again, the technology is neat, but why would anyone use it?

For Bitcoin, started as an loose alliance of Cryptonomicon-dreaming anarcho-libertarian-techies-goldbugs who wanted to disrupt the power of states on the economic system, then the real killer app was darknet drug markets. The first was enough to establish the market; the second was enough to make sure it didn’t go away.

It’s the same problem with Ello, which was going to disrupt Facebook, but worse, because there was a natural initial Ello community (analogous to the BitCoin techno-anarcho-goldbugs) and there isn’t for the blockchain HRB.

The lesson: network building has to be primary and technology secondary. That’s why we started CommonWell, and why Argonaut has been successful.

David - Well, I think the folks who believe in Health Record Banks might find this useful. They (HRBs) have a terrible problem around trust — doctors don’t believe the patient-provided record is complete or tamper free.  Solving that problem (without blockchain) requires lots of centralized services – which are too expensive for anyone to want to pay for. Ergo, no real world HRBs.

But what if any HRB provider simply aggregated blockchain-signed “deposits” of the record from the patient’s physicians?  Then any provider could consume the record with trust that it was (complete?) and tamper-free.  (Each HRB provider would deliver the record via a SMART app, etc.)

(I’m unclear on the “complete” part — there might be some requirement that actual payment for services creates the blockchain record?)

Something like this might be a valuable enough use-case to explore?

Arien - OK, let’s assume the existence of a working and good blockchain implementation of an blockchain Health Record Bank (bcHRB) and a SMART app that serves as the bcHRB adaptor.

Argonaut, SMART, etc. gives us the ability to install the adaptor on every EHR in the country without needing to coordinate (yay! Argonaut).

OK, now what? We need the thing that starts up the network, because bcHRB is definitely a network-effects service. Doesn’t blockchain require us to distribute processing, like BitTorrent? But who pays for the compute time? (In BitCoin, the miners pay for the processing, with value based on mined bitcoin).

OK, maybe (hand waving) the SMART apps also supply the compute, which means they cost something, which means I need to pay for them? Maybe each bcHRB SMART app is hosted on Amazon VMs that supply the compute nodes? Also, I need to coordinate a bunch of people using the bcHRB in a community so that anyone gets value, and I need to make sure there’s enough value each time a provider hits the SMART app.

Back to network building again.

David- I’m getting over my head now, but I think in BitCoin, it’s only the gold miners who have to do lots of computing.  For individuals who simply want to trade coins, there is no serious processing.  (There is some network overhead to download the chain, but the processing is modest.) For example, I was able to buy a bitcoin, download a wallet to store it, and then purchase things.  It didn’t cost me anything other than the purchasing the initial coin. No serious mining, if all you want to do is use the network.

And any group who creates a blockchain from scratch can elect to pre-seed the network with as much “gold” as they want.  The Ethereum people gave out 20M coins to the folks who volunteered to develop the code.

So  I think “mining” is irrelevant to the HRB model since the chain is not carrying around an inflatable currency – it’s simply carrying around a complete record of all “deposits” of data to the bcHRB.   Each deposit is eventually verifiable to anyone who wants to sample the chain. Maybe the way to think about it is that anyone who has created a snippet of medical data can “deposit” it into the bcHRB network for “trading” securely with anyone else.

I would envision that the chain verification costs (which I think are very modest) would be borne by the folks who use the data – for example, the providers who access the record, or researchers who get your permission to use your data.

But I don’t know enough to be very sure of any of this!

And it might be possible to build something functionally equivalent without any blockchain at all.  But as soon as you start talking about certificate authorities and PKI infrastructure and such, you get into centralization and coordination overhead. Which is what BitCoin supposedly avoids.

Arien - To summarize:

Working blockchain systems require a set of compute nodes.
Those nodes verify the transactions, and (partially) hold the complete history of blocks.
In BitCoin the nodes are providers by BitCoin miners, who essentially get paid for running compute (mining == blockchain transaction verification)
In bcHRB, the compute nodes must be supplied by somewhere
BitCoin solves the “who runs compute nodes” problem by creating an economic incentive to do so; the same problem must be solved by bcHRB by ??

 I think David and I are saying the same thing: the compute costs are borne by the SMART app users, which is where I got to as well, which is how I got back into economics and network building.

John - I'll reassure the industry that we do not have attention deficit disorder and that we're still laser-focused on FHIR, enabling infrastructure, and governance.   Blockchain might solve one of the trust /data integrity problems we've that folks like Gary Dickinson have raised at HIT Standards Committee meetings.    Definitely worth further thought.

Unity Farm Journal - Fourth Week of March 2016

I’ve returned from China and re-established my daily routine on the farm.  In my absence Kathy kept the animals safe and warm.   She watered and nurtured all the indoor and outdoor crops.   She served as point of contact for all the people in our lives.  She's remarkable.

All is perfect on the farm and it’s as if I never left.

Here’s what the hoop house beds look like as of the last week of March.

We had one last winter storm this week with 4 inches of wet sticky snow.   It melted quickly and the weather cleared with brilliant red sky at night.

Now that spring is here we’re completing those projects that require dry, thawed ground - building our summer pig paddock, putting up the blueberry netting, repairing fences, and pounding the poles for the hops trellis.  

The creatures on the farm are glad that all the humans have returned.   The pigs are getting the belly rubs, the dogs are getting their runs, and alpaca are getting their chopped alfalfa/molasses breakfast.

Soon the Shiitake mushrooms will begin to fruit and we’ll bottle the cider which has mellowed over the winter.  

I look forward to a bit less travel and a bountiful Spring in the months ahead.

CareKit as an Enabler for Patient Generated Healthcare Data

As we move from fee for service to alternative payment models/value-based purchasing we will increasingly measure our progress based on outcomes and total medical expense.

HealthKit was an enabler that led Beth Israel Deaconess to create BIDMC@Home, an iPhone and iPad app that uploads internet of things (blood pressure cuff, glucometer, scale, activity, sleep data etc.) to our electronic health record.

CareKit, announced by Apple this week, takes us one step further on our wellness-focused journey.

Our vision is that objective data such as weight and blood pressure needs to be combined with subjective data such as activities of daily living, mood, and adherence to care plans in order to create a true measure of outcome.

If you take  your beta blocker for blood pressure control but feel listless and unmotivated, that is not a good outcome.

Apple’s middleware (HealthKit, Research kit , Carekit) has enabled us to connect devices in BIDMC patient homes and this Summer will enable us to collect answers to clinician generated questionnaires with dashboarding of the subjective and objective combined results.

We believe that mobile devices such as iPhones will become the predominant means by which patients interact with BIDMC.    Your phone will be the repository of your medical record, the means by which you collaborate with your provider, and the vehicle for submission of data to your care team.

Today, 80% of all BIDMC publicly available resources (websites, portals) are accessed via mobile devices.  The desktop is dead.   The phone is the future.

Kudos to Apple for enabling simple integration of devices in the home, collection of patient provided questionnaires, and bidirectional exchange of care plans.

I know that the current FBI/Apple security issues are controversial, but if we’re going to use the phone as the means for patients to coordinate healthcare, we need to ensure data integrity.   I support the idea of government entities obtaining cloud-based backups of devices when courts grant subpoenas.   I do not support the idea of compromising the integrity of phones when they are serving as the link between patient devices/patient sourced  healthcare data and providers.

The combination of sensors in the home, patient/family engagement, and security/data integrity is the secret to success in alternative payment models.   We look forward to piloting several new apps in 2016.

Unity Farm Journal - Third Week of March 2016

Kathy has been running Unity Farm while I’ve been in Texas and China.  The weather in Sherborn has been mild with light rain.  The first round of newly germinated seeds is planted in the hoop house and enjoying the warmth of early Spring,  Kathy is watering everything at the end of the day to keep the seedlings moist.    The Rex Boston , Buttercrunch Bibb and Nancy Bibb lettuce is almost ready to harvest.

Carrots, beets, spinach, peas, and beans are growing fast.   The tomatoes, eggplant, and pepper seedlings are nearly ready to move from the germination trays to 4 inch jiffy pots.

All the creatures are doing well, although the dogs and pigs miss me.   I’m the one who meets them on their own terms - crawling through mud, rolling in hay, and petting bellies while rubbing noses.   Kathy is a good petting proxy, although she remains standing.

Kathy also tucks in the pigs every night.   Here are two pigs in their blanket

The geese continue to defend their territory chasing the ducks and chickens from their nests if they get too close.   Our geese are very kind in general, but we’ll have to watch their “spring fever”

The driveway project is beginning and the 25 year old asphalt is being scraped away today so that a new gravel bed can be installed and allowed to settle for a month.  It’s great that we left driveway rehab until the very last, since the truck traffic that accompanied the building of Unity Farm infrastructure over the past 4 years was rough on it.    At this point, we’re to the point we can just run the farm, reducing the cost and effort of creating new things.   For a summer that includes a wedding, a bountiful harvest, and adding a few hundred more Shiitake logs to the woodland crop area, fewer construction projects will be welcome.

I fly from Hong Kong today to Los Angeles to help my mother with home maintenance and keynote the American Dental Association conferencing where I’ll offer thoughts on the ideal shared dental/medical electronic record.   Then home on Monday morning.   No more travel until Friday in Canada and next week in London.  Logan airport is my second home this Spring.

Dispatch from China

On Saturday I flew to South by Southwest for a keynote about cybersecurity.   Luckily, President Obama warmed up the audience before I arrived and offered balanced remarks about the need to balance privacy and security.   Two hours after my presentation, I flew to Hong Kong for all day meetings in Shenzhen.

The themes we discussed are very similar to those facing the US

How do we implement structured electronic data collection in support of a learning healthcare system, quality measurement, and clinical trials/research?

  Do we replace existing systems or augment them?

  How do we exchange data?

  How do we ensure security?

  How to do we manage the change and mitigate risks of clinician dissatisfaction?

There are a few aspects of China that help us address these issues.    There is a great willingness to change.  There is less regulatory burden at this point.   There are significant resources available.   In someways, China in 2016 is like the US at the beginning of the HITECH era.

From Shenzhen, I traveled to Suzhou and presented an overview of innovation in team-based care,  mobile, cloud, analytics.  

From Suzhou we drove to Shanghai for meetings with academic, government, and industry leaders.

The advantage of working in China is the 12 hour time difference with Boston.  You can work 12 hours in China, then work 12 hours in Boston every 24 hour cycle.   Back to the US tomorrow!

Unity Farm Journal - Second Week of March 2016

Spring is here.   Although we’ve not quite reached the vernal equinox (March 20), the temperatures this week have been consistently above freezing.   The spring peepers are beginning their mating rituals in the vernal pond and their  chorus is soothing us to sleep every night.     Here's a recording from our bedroom window.

With Spring-like weather, every animal imaginable is awake, searching for food and raising young.  On my nightly checks of the alpaca this week I’ve seen raccoons, skunks, coyotes, night herons, and groundhogs.   The skunk cabbage is in bloom and the bees are exploring the woodland looking for food.   The poultry crumble is a good source of protein since pollen is scarce.   It’s  covered with bees.

With Spring, the males begin competing for mates.   We found a pool of blood behind the coop and the source was two roosters fighting so violently that one knocked of his spurs (that’s like knocking off a finger).   They will grow back.

Running Unity Farm is a continuous educational experience.  In previous blogs I’ve described my 4 seasons approach to organic vegetable production including the germination stations I’ve built indoors and  outdoors (in the hoop house).    This week, with temperatures in the 70’s the sprouts in the hoop house got too hot.   It became clear to me that germination is best done in a controlled environment, so I’ve moved all the germination lights, heat mats, and trays to tables into the house.  

Thus far, I’ve had great luck transplanting germinated seeds after 3 weeks.  Here’s what the hoop house looks light today (in mid-March) using my transplant technique.

With my daughter getting married in May, I’m adding a few improvements to the farm near the place where she’ll get married (the grape pergola).   Last Saturday, I re-built this fountain using 3 boulders from the farm.   The engineering of the plumbing was interesting - a four season, easy to maintain pressure balanced water circulation system.    I used a magnetic, low power 1800 gallon/hour pump , polymer fittings from Shark Bite and stainless steel clamps.   The end result - nothing to maintain, since there is nothing to rust or wear out.

The only remaining infrastructure project before the wedding is repaving the driveway, which was last maintained in 1993.   Wish me luck!

Another Perspective on HIMSS 2016

Several BIDMC System IT leaders attended HIMSS this year to help us select the most innovative solutions for our 5 strategic pillars.

Manu Tandon, CIO of Beth Israel Deaconess Medical Center shared his notes with me and with his permission, I’d like to share them with you:

“Population health conversation last year was about maximizing revenue for the organization. Now it's about identifying and managing cohorts of patients using patient generate data as a source. The best thinking we saw aligns very well with ours. A workflow oriented EHR centric model that closes the gap between operations and analytics is the way to go. Separate big data platform based approaches are fading away.

Sensed a very noticeable increase is the use of mobile platforms and mobile  apps in marketing literature. Mostly stand alone apps with some integration capability. The EHR vendors in general seem to be behind the curve on this especially for two way interactions. The pure mobile app vendors are struggling building API based integration with a majority of EHR vendors. They are all, however, striving for integration. Again felt our approach was validated here with our crowdsourcing based WebOMR API driven mobile platform strategy.  Without payment model reform the commercial adoption would lag.

Our thinking on patient centered care team coordination is ahead of the market.  Secure texting as a standalone solution has limited potential. The real deal is in an EHR centric approach that is personalized, integrated and keeps documentation in natural alignment with communication.

The conversation around inclusion of patient generated data in the care continuum took a lot of bandwidth at HIMSS. Some are doing this already with some level of integration but all seem to be striving toward this goal. Payment reform to compensate for this is the catalyst they are all waiting for.

The baton for interoperability - the buzz word of past HIMSS - has clearly passed from the federal domain to the private sector.  The near future may belong more to targeted interoperability vs a broad based all data everywhere all the time type of solution.

Overall, felt like our approach to population health, care team collaboration, mobile applications, internal improvements and targeted interoperability was strongly validated.  Strong governance and a heads down workman like approach is our best chance to progress on this journey. "

Unity Farm Journal - First Week of March 2016

I’ve been traveling this week, so Kathy has been carrying the full weight of running Unity Farm.   Here are her notes from the past few days:

“The mother coyote is raising another litter of kits and she’s clearly anxious to feed herself and them.   She’s leaving the den twice a day (during daylight) in an attempt to grab a chicken, duck or guinea (the geese are too big).   As usual, all 60 guineas gather into a flash mob as soon as she arrives and chase her back to the den.  There is definitely strength in guinea numbers.    We really do not want to harm her, but we also do not want to lose any poultry.   A neighbor suggests a paint gun - frightening but not damaging  - as a coyote deterrent.

The salad greens are growing nicely in the hoop house beds and the germination area.   The peas have sprouted and our late winter crop is enjoying the warmth of the approaching Spring.

The geese are laying every other day.  Both Gabrielle and Hercules are using the nest box near the front door woodpile.

We’re creating a new summer pig paddock in the barnyard which means relocating the wood splitting area.   There will be cool shade, plenty of mud and  breezes coming off the drumlin to keep the pigs comfortable in summer.  Since they do not sweat, they cannot stay in the sunny winter paddock

All this activity is its own fitness program.   Who needs a spin class when you’re running a farm!”

This weekend I’ll be moving wood to clear land for the new paddock, rebuilding one of garden ponds that leaked over the winter, and harvesting vegetables that have matured in my absence.   The post HIMSS week is relatively sedate but next weekend, I’m flying to Austin for a South by Southwest keynote, then leaving for Hong Kong for a few days of teaching/mentoring/planning in  nearby Shenzhen with side trips to Shanghai and Suzhou.    From China, I’ll fly back through Los Angeles to keynote an American Dental Association conference, then return to Boston.   April brings a 2 day trip to the UK to join Bob Wachter and colleagues for an IT review of the National Health Service.  May includes a weekend commencement speech in Texas.  Thankfully there will no travel between May and an October 28 New Zealand keynote.    Kathy’s days alone on the farm will be very minimal this Summer, which is great because our daughter’s wedding is coming up in late May.

It’s good to be home.

Dispatch from HIMSS

Every year I walk the HIMSS floor and speak at HIMSS events with the hope that I can distill the conference sensory overload into a few key themes.

In the recent past, big data, interoperability, personalized medicine, population health, and wearables were buzzwords in every booth

This year, the buzzwords were replaced by one overarching concept - providers and vendors must innovate or die.

In the next 24 months we’ll see an accelerating evolution of fee for service into alternative payment models fueled by MACRA and MIPS.    We will no longer be driven by compliance imperatives (Meaningful Use, HIPAA, Affordable Care Act, and ICD10), but instead will need to improve outcomes in order to survive financially.    No one is completely sure how to do that, but there are enablers.

Providers will be responsible for the care that their patients receive throughout the community - inpatient, outpatient, urgent care, post acute care and home care all contribute to total medical expense and wellness.   Some of the care may be delivered by people and organizations outside the of the control of primary care givers.  The only way they can succeed is by aggregating data from payers, providers, and patients/families in an attempt to provide “care traffic control”

Doing this requires tools for team-based care and communications, functions that may not be provided by the core EHR vendor.   Instead, an ecosystem of apps, services, and connectivity will surround the EHR to enhance usability and workflow.  A few idea/products to watch

Surescripts National Record Locator Service - a master patient index which provides pointers to the medical records of patients at every site of care.  

Commonwell - a collaboration of vendors also providing master patient index services.

DirectTrust - creates a scalable way for trading partners to establish trust relationships without requiring bilateral participation agreements with every participant. i.e. without DirectTrust 20 trading partners would require 20x20 (400)  agreements. DirectTrust also supports a national provider directory

FHIR-based application program interfaces (APIs) - with APIs, provider to provider and patient-provider data exchanges are simpler to engineer and support.   Just about every EHR vendor has agreed to support FHIR APIs this year.

Cloud-hosted services - the era of locally hosted licensed software is ending and being replaced by agile services that can be turned on and off with minimal capital investment.   As healthcare gets bigger through merger and acquisitions it will become increasingly important for affiliated organization to leverage a common pool of cloud hosted services.

In the View from the Top keynote I did with Jonathan Bush (the yin to my yang) we left the audience with a call to action.

It is possible today to connect the healthcare ecosystem using the enablers listed above.   We do not need to wait for the perfect standard or the next round of prescriptive regulations.

It’s happening now and companies that are early movers in telehealth, connectivity, and care management will out compete the laggards

It’s time to replace compliance (fear of failure/sanction) with determination (joy of success) to make healthcare better.    Although some of the innovations sound like they could increase risk (cloud/mobile/apps), in fact they are likely to reduce risk by leveraging the experience of a larger number of people outside any given institution.  

I left HIMSS this year with great optimism.   Vendors, technologies, and incentives are aligned for positive change.   2016 will be a great year.