Unity Farm Journal - First Week of July 2016

When running a farm you sometimes feel like MacGyver - given a few 2x4s, a piece of hardware cloth, and a box of bags, create a compost bagging machine.

Every year, we produce about 10,000 pounds of organic compost from alpaca manure (a 16:1 carbon to nitrogen ratio) and timothy hay (a 45:1 carbon to nitrogen ratio), resulting in a perfect blend of Unity Farm “Llama beans” which has a 25:1 carbon to nitrogen ratio.   Alpaca compost has been described as “gardener’s gold” because of its perfect balance of nutrients.    One cubic foot weighs 33 pounds, so we can produce 300 bags for sale each year.  How do you bag 10,000 pounds of composted manure - the prototype is shown above.    10 shovelfuls of compost onto a sifting screen of 1/2 hardware cloth results in one cubic foot of fine compost in the box below.   At the bottom of the box is a cutout for polypak heat sealable bags.   Just move the compost into the bag, then set it in the heat sealer.      We’re planning to retail it for $9.99 per 33 pound bag at Tilly and Salvy’s farmstand

Our next step is to add a motorized trommel so that the sifting is done automatically.

We’ve delivered fresh organic sweet basil, swiss chard, and purple beauty bell peppers to Tuilly and Salvy's farmstand this week.  Cucumbers, peppers, and tomatoes are all ripening fast.

Our early blueberries are just about ready to pick - all our netting is up so the blueberries, gooseberries, and raspberries are protected from the woodchucks, birds, and squirrels.

We’ve been hard at work hatching poultry and raising chicks.   At this point, we’re ready to integrate the oldest chicks with the adults using our mini-coop, the inserts I built into the large coop to isolate new arrivals from the adults.   After a few weeks in the mini-coop, they’'ll be ready to free range.   Although we generally try to limit the number of guineas we add each year, this summer we’re adding 18 birds with entirely different genetics to the flock.     Since our current flock is 60 birds descended from an original cohort of 11, it seems reasonable to add some diversity.

We’ve been very lucky with all our creatures and typically only lose one or two birds a year to coyotoes, hawks, fisher cats, foxes and racoons.   This week, one of the female guineas decided to build a nest in the forest and not return to the coop.  Unfortunately we found a large collection of features in the orchard which suggests the nest was raided during the night and she was eaten.  

Now that we’re selling organic fruits, vegetables, mushooms, compost, and herbs, you’d think we’d make a small fortune in farming.   Although that’s true, remember, it requires a large fortune to start and operate the farm.  Margins are razor thin.    We measure our income, not in dollars but in job satisfaction!

This weekend we’ll be spinning our first Summer honey  - at least 60 pounds.   With our current 30 hives, we expect about 1200 pounds of honey every year once the colonies are fully established.

An EHR implementation of The Checklist Manifesto

Boston Physician Atul Gawande wrote The Checklist Manifesto in 2009  stressing that medicine should adopt “pilot’s checklists” to ensure that operating room teams are “ready for takeoff” before a scapel is ever opened.

BIDMC implemented The Checklist Manifesto ideas in software in 2010.

Here’s the “Time Out” done among all OR team members before a case beings - it includes a list of staff participating in the timeout, the agreed upon procedure, the verification of consent, appropriately marked operative site, patient identity verification, and best practices for prophylaxis.  

We also have procedure specific checklists for each operating room role.   Here are transplant checklists for surgeons and nurses

Here are spine surgery checklists for surgeons and nurses

Many complain that electronic health records create burden without significant benefit.   Implementing checklists into the workflow of EHRs in the operating room is high value, ensuring good team communication, while also reducing error.   A win/win for everyone!

Unity Farm Journal - Fourth Week of June 2016

Unity Farm is now an organic certified producer of vegetables, herbs, mushrooms, nuts, fruits and seedlings!   Here’s our official designation

As I mentioned last week, I’m now doing increased documentation - daily logs of compost temperature and comprehensive recordkeeping about mushroom innoculation dates.

Yearly inspection for organic certification compliance is just one of our regulatoryequirements.    At the moment we also have

*Commercial kitchen designation with yearly health department inspection (including refrigeration facility review)

Massachusetts 61A working farming designation with specific documentation of cultivation and produce sales.

Bonded winery/cidery with monthly filings to state and federal entities. Labels must follow specfic guidelines including 8 different elements.  Here’s what our cider label looks like

Our next regulatory adventure will be designation of Unity Farm as a charitable farm sanctuary for rescue animals.    There is a process for everything and persevence is generally successful when seeking government approval.

Speaking of regulations, who knew that ICD-10 could help with farm documentation?

Our pigs are remarkable companions and every night I offer them sweet grapes before tucking them in.   Sometimes they get a bit over excited by their treats and Hazel Marie jumped for grapes, chomping my thumb slightly.    The photo is below.   The great news is that ICD-10 completely covers this situation.

This was professionally coded as 2016 ICD-10-CM Diagnosis Code W55.41XA : Bitten by pig, initial encounter

Luckily, no infection set in, but if it did, that would be W55.41XS  Bitten by pig, sequela

If she would have been excited enough to knock me over, that would be  W55.42XA
Struck by pig, initial encounter.  

Isn’t ICD-10 grand!

This weekend I'll be maintaining trails, planting scallions, moving chickens from the brooder to the coop, packaging manure (Unity Farm Llama Beans!), and building bee standards for our expanding hive collection, now up to 30 hives in production.    It's Summer and the living is easy.

Why Apple HealthKit in iOS 10 Makes View/Download/Transmit Real

Meaningful Use Stage 2 has a requirement that I’ve always considered to be the “cart before the horse” - patients must be able to View/Download/Transmit their data.   Viewing is great - we’ve done that at BIDMC since 1999 for all patients and all data.    Download makes little sense since at the moment there is nothing a patient can do with a download.   Of the 2 million patients at BIDMC, not one has ever requested a download.    Transmit makes even less sense since there is no place to transmit the data to.

All of this will change with Apple iOS 10.    What has Apple done?   As an extension to HealthKit, they’ve built a CCDA viewer which can display transition of care documents in a patient friendly format.   They’ve modified Apple mail and the Safari browser to understand CCDA XML headers and automatically offer to open the documents in HealthKit.

The end result is that developers can easily enable download since a URL to a CCDA or email attachment works seamlessly.  BIDMC developed the code in minutes.   Here’s what a BIDMC medical record looks like in  iOS 10.

Once the CCDA is in the Healthkit database, enabling an app to transmit it is also easy.   We’ve already done that with HealthKit data like blood pressure, glucose and weight.

So although View/Download/Transmit made little sense when it became a requirement (and no one used it, requiring Meaningful Use requirements to be reduced to ONE patient instead of 5% of patients),  HealthKit in iOS 10 will enable an ecosystem of apps to provide patients and providers with a highly usable workflow for data exchange.

CareKit, another Apple development, enables care plans, patient-facing subjective data gathering (what is your mood, how is your wound healing), progress dashboards, and secure communication. With objective data integration, subjective data gathering, CCDA viewing, care  plan dashboards and communications, the suite of  Apple tools empowers developers to create the next generation of patient engagement products.

I have no stock in Apple and no financial relationship with them, so I say this purely as a developer -Apple’s tools are likely to have a very significant impact on the healthcare ecosystem in the years to come.

Unity Farm Journal - Third Week of June 2016

The baby geese are now old enough to free range with their parents, so they are wandering through the forest and barnyard from 7am to 7pm, occassionally stopping for a pool party in the pond.    We believe we have two male and one female young geese, bringing our total to 3 males and 4 females.   Will be interesting to watch their dynamics and relationships as they age.

 Every week on the farm has some unique learning experience.   What should you do when you find a baby blue jay on the ground, either fallen from the nest or having failed its initial flight?   The general rule of thumb is to do nothing .  The parents are likely nearby and will feed it until it flies.   However, if it falls into a danger zone, you really need to move it to safety.   In this case, it fell into the mouth of Bundle, one of our Great Pyrenees.   I was there when it happened, so I was able to rescue the blue jay quickly and move it to a place of safety.    We used pine branches to create a makeshift nest in a tall rhododendron, keeping the bird off the ground.   We fed the bird fresh mealworms and it hungrily took them from our hands (looks like Angry Birds).  

The parents roosted in a tree nearby and watched over the baby for two days until it was able to finally join the family on its own.      Recognizing that this is likely to happen again, we created a permanent baby bird safety area in the forest - away from the dogs, chickens, geese and guinea fowl.  It’s 12x12 inches square with a 2 inch raised lip, supported by 2x4s about 5 feet up on the side of a black birch tree.   Whenver we find a baby bird on the ground in a dangerous area we can simply move it to the “safe room".

Although the marketplace for guinea fowl is not that robust, we did raise 25 chicks from eggs and had remarkable success.   Our guineas are so healthy that their offspring thrived without a single death.    When you buy guineas commercially (shipped via US mail), you can expect up to 30% losses.   We did order 30 guineas of varied genetics to bolster the Unity Farm gene pool and thus far, we’ve lost 4.     We’ve sold about 30 guineas thus far and we’re likely to end up adding about 15 to our flock.

We’ve also added new chickens and bantams to keep the flock diverse.   We’re selling some of the chickens, but likely we’ll end up adding 15 new chickens to the flock.

We’ve very careful with our poultry population management to avoid overcrowding and pecking order battles while also maintaining diversity.

As a federal/state bonded winery/cidery, we have a great deal of regulatory/compliance work to support and this week I’ve worked with the  Alcohol and Tobacco Tax and Trade Bureau (TTB) to get access to the Certificate of Label Approval (COLA) system so that we can electronically submit our labels for approval to the government.   Every label must have 9 unique characteristics including a health warning statement https://www.ttb.gov/pdf/brochures/p51901.pdf   It must be approved before bottling but can be altered without reapproval to change the vintage year, alcohol content, ingredients etc.   We’re hard at work designing the Unity Farm labels for mead and cider.

The pigs continue to grow and are always demanding attention.   Every night I feed them grapes, give them a belly rub and tuck them into their quilts in the pig house.   As some have said, “when I die I want to be reincarnated as a Unity Farm pig”!

This weekend we’re delivering basil, eggs, mushrooms, kale, and peas to Tilly and Salvey’s farm stand.   Strawberries and blueberries are just a few weeks away.   I’ll do trail maintenance and begin preparing for the Fall seedlings - the work of preparing for the next season never stops!

Why I Disagree with the Snake Oil Analogy

Earlier this week, the American Medical Association CEO called digital healthcare products modern-day "snake oil"

As a provider and a technologist, I think we need a deeper dive to understand the issues, avoiding the kind of hyperbole that’s so common in politics today.

Paul B. Batalden, MD, Senior Fellow, Institute for Healthcare Improvement (IHI), once said “Every system is perfectly designed to get the results it gets”.

Let’s take a brief look at the history of national healthcare IT efforts from 2004-2016 to understand how we’ve achieved exactly the results we designed.

In 2004, National Coordinator David Brailer wrote “The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care” suggesting that we move from a paper-based industry to electronic transactions, we share data, we do population analytics,  and we engage patients/families.

All 5 of the national coordinators - Brailer, Kolodner, Blumenthal, Mostashari and DeSalvo have followed these 4 basic ideas.

As a country, we invested $35 billion to move existing transactions from paper to electronic form and 85% of our clinicians/hospitals achieved that.     We also required patient access to educational materials, which have appeared in the form of a multiude of stand alone apps.   We did not suggest a fundamental redesign of healthcare workflow, we suggested a digitization of existing paper processes.   We accomplished exactly what we set out to do.

Did we share data?   Some would argue that we have not achieved interoperability.  However, what is your definition of interoperability and the criteria for success?  The work of the past decade has focused on e-Prescribing, public health reporting, and  laboratory resulting.   All of those have been achieved with very high adoption rates.   We did not focus on pulling data from disparate sources so that information is available at the point of care just in time.     We accomplished exactly what we set out to do.

Did we enable population health?    EHRs and related tools can support basic queries about the patients in a provider’s panel.   We did not focus on creating care management workflow based on guidelines, protocols, and pathways.  We accomplished exactly what we set out to do.

Did we engage the consumer?   Most patients have access to a portal of their results.   We did not focus on the kind of workflow supported in Apple CareKit - care planning, patient generated healthcare data, dashboards, and mobile communication tools.   Again, we accomplished exactly what we set out to do.

There is no snake oil.   We created the digital foundation that is a prerequisite for the next generation of tools which will focus on:

*team-based workflow rather than digitizing existing processes (note - requires revision of numerous existing CMS regulations)

*pulling data from the patient’s lifetime historical healthcare encounters (note - requires a national master patietn index/record locator service/provider directory)

*supporting care management workflow (requires tools that do not yet exist in the marketplace to enroll cohorts of patients and provide precision-medicine inspired care plans for each of them, supported by a customer relationship management system for healthcare)

*mobile-centric patient/family engagement solutions that start from a careplan and provide easy to use mobile transactions to request services, exchange data, and receive advice.  (note - requires a set of mobile apps based on middleware such as Apple CareKit)

As I’ve said in several posts, more Meaningful Use is not the answer.  Relying on the ONC 2015 Certification Rule is not the answer.  

Rather than suggest that vendors are selling the electronic equivalent of snake oil, the AMA should recognize that the regulatory efforts of the past several years have achieved exactly the result that was intended and that stakeholder organizations such as the AMA should suggest  a small number of desirable outcomes  as our next goals.   Government should provide incentives to achieve those outcomes via MACRA/MIPS and the private sector, working with stakeholders (patients, payers, and providers) should innovate to deliver the needed technology.

Meaningful Use has achieved its goals and we need to accept that the journey we’re on is incomplete, not off course.    We all need to unify on defining the future we want and aligning government, providers, and industry to establish a trajectory to get us there.

As Yogi Berra said, “If you don't know where you are going, you'll end up someplace else.”

There’s no snake oil on the road ahead.
 

Unity Farm Journal - Second Week of June 2016

This week we completed our organic inspection, which was very much like a Joint Commission visit.   The “commissioners” arrived for a suprise inspection on a Monday morning.  They covered hundreds of criteria from water purity to seed use to composting techniques.  They reviewed documentation and checked every package of supplies for appropriate OMRI compliance.   Recordkeeping in organic farming is key such as daily compost temperature measurements that ensure a pathogen free product.     I learned an immense amount during the inspection and will be enhancing a number of processes and controls on the farm.   We should hear back from the certification organization soon.   The scope of our certification includes fruits, vegetables, mushrooms, compost, and seedlings.

Our baby geese are growing up and now free range with their parents a few hours a day.   We ensure they are kept safe during the middle of the day when hawk predation is at a peak.     They are maturing fast and we’ll be keeping all three as a permanent part of the Unity Farm community.

Our community includes numerous native animals that make Unity Farm their permanent home.     A beautiful woodchuck (a kind of marmot) has decided to make a home in our winter paddock.   Many would consider a woodchuck to be a pest, destroying produce and disrupting the ground toplogy.   All our orchard trees are caged and our vegetables are in the hoop house, so at the moment we’re not losing any produce to “Chuckette”.  

A fawn was born this week and within a few minutes she was running around the farm driveway with her mother.

We continue our weekly harvests of mushrooms and vegetables.   Here’s what the growing areas look like this week.

Finally, Kathy is very busy managing bees.   She’ll have 28 hives and more than 250,000 bees under management this Summer.

This weekend, all the families are gathering for the first time since my daughter’s wedding.   Should be a great opportunity to check in on post married life!

A Time of Uncertainty

The upcoming presidential election has everyone spooked  - what if Donald Trump is actually elected?  What will the transition of administrations, regardless of who is elected mean to healthcare and existing healthcare IT regulations?     Will our strategic plans and priorities need to change?

I’ve spoken to many people in government, industry and academia over the past month about the rapid pace of change stakeholders are feeling right now.   Here are a few of their observations:

1.  In the next year or two there will continue to be consolidation  in the healthcare IT industry.    Many smaller EHR companies will fold due to declining marketshare and some established incumbents with older technologies are likely to sell their healthcare IT businesses or reduce their scope.

2.  Mergers and acquisitions will continue to accelerate, reducing the number of stand alone community hospitals and practices.   The end result is that the market for software supporting midsize hospitals and small group practices is likely to shrink since ACOs/networks/healthcare systems will probably mandate a single centralized EHR solution for the enterprise.

3.  Although the election may change the regulatory burden, many incumbent vendors will be spending the next year or two complying with certification demands, reducing their ability to innovate.     It’s quite a conudrum.  The market is demanding innovative solutions in the short term, but vendors cannot produce them because their development resources have been co-opted by regulatory demands.    Thus, vendors may see a reduction in new sales, which will diminish their ability to hire new staff to meet the regulatory demands, putting them even further behind.     It reminds of a classic unstable system - beer pong.  The more you miss, the more you drink, the more you miss.   The more regulation, the fewer new sales, the less ability to deal with regulation.

4.  The capacity of hospitals to pay large sums for EHR implemention and operation will be reduced as margins shrink during the fee for service transition to value-based payment.  Vendors will be pressured to offer cloud hosted subscription models with standard configurations that are less resource intensive.    Customization will be less attractive than a good enough platform that is affordable and highly usable.

5.  As I wrote about last week, innovation is likely to come from one of two areas - smaller/agile companies that are not yet overwhelmed with regulatory burden or companies on the edges of the healthcare IT industry such as Apple, Google, and Amazon.     It’s hard to predict the winners.   There was a flurry of small startups in 2014-2015, but in 2016 we’re seeing them close/sell/merge.  The pace of new startups has slowed.  

What kind of innovation do we need?  I have a “top challenges” list that includes

*A master patient identifier for the country
*A provider directory for the country
*A consent registry/record locator service for the country
*A customer relationship management platform that supports care management
*A groupware communication tool for healthcare
*A set of security solutions that makes two factor authentication/endpoint encryption easier
*A mobile platform for patient/family engagement that provides usability and high value transactions to the consumer
*A telehealth/telemedicine platform that supports documentation/billing in the cloud
*An interoperability platform that leverages cloud technologies to seamlessly provide clinicians with the information they need when their need it
*An analytics platform that notifies/alerts clinicians when something needs to be done - providing wisdom, not just a flood of data

I’m increasingly on the lookout  for organizations which will address these challenges during the uncertain 24 months ahead.    The advantage of being at Beth Israel Deaconess is that I can draw on all sectors - payers, providers, patients, established industry and startups to aquire potential solutions.    Situational awareness and agility are a must for the months ahead.  I’m keeping my running shoes on!

Unity Farm Journal - First Week of June 2016

My daughter's post wedding bliss was followed by the newlyweds move out of Tufts (Medford, MA) and a move into a new apartment in Brookline, MA.   My son in law will be attending graduate school in the Longwood Medical Area.

Over the past few years, I’ve worked on many moves - parental moves, our own moves, and now my daughter’s move.   At this point, everyone in the family is ideally situated for the next phase of life.   I can only hope we’ll have a decade without any more moves!

We’ve had a very unusual May with high heat and high humidity.    That caused the lettuce in the hoop house to bolt so we’ve harvested all the Boston, Bibb, and Romaine lettuce, replacing it with peppers, tomatoes, cucumbers, basil and eggplant.    We’ve increased irrigation and kept the hoop house sides maximally opened.  Even the geese are using our water features as drinking foundations.

We have our final inspection for organic certification next week.   Once that is done, we’ll be able to use “USDA organic” label on all our products.

We’re starting two new businesses on the farm that will enhance our profitability. We generate about 10,000 pounds of finished alpaca compost every year.   We’ve found a local market for organic compost and will be using the product name “Unity Farm Llama Beans”.       I built a compost screener and we've purchased one cubic foot poly bags so that we can cleanly package our aged/fully mature compost.  The only ingredients are timothy hay and alpaca/llama droppings, all aged 2 years after 140F composting and monthly turning.     Who knew you could turn poop into gold?

We’re also selling organic seedlings to our local farm stand, Tilly and Salvys in Natck.   You’ll find cucumbers (slicing and pickling), tomatoes, and eggplant seedlings from Unity Farm ready to plan in peat pots.   This weekend, we’ll deliver 50 basil seedlngs, ready to plant.

Over the weekend, we’ll harvest Shitake mushrooms,lettuce, kale, and eggs.    

It feels like Summer, but in just a few weeks, we'll start our Fall seedlings.   A farmer never rests.

Making a Difference

When my father died 3 years ago,  my comments at his funeral  noted  that the greatest aspiration any of us can have is to make a difference in the world.  My father’s life made a difference.   

I’m always self critical and analyzing my own life.  I moved to Boston 20 years ago this month.   In those 20 years of service to BIDMC, Harvard, numerous federal organizations,  international governments, and industry, I’m hopeful that I’ve laid a foundation for 20 more years of trying to make a difference.  It’s hard to forecast the best path to have an impact on the healthcare ecosystem, but I can try.

The past 5 years belonged to government - with $34 billion spent on healthcare IT as a result of HITECH, the Meaningful Use program accomplished the goal of moving clinician practices and hospitals from paper to digital systems.    Although many challenges remain - improving workflow, enhancing quality/safety, and ensuring usability, the basic platform on which we can build future innovation has been created.    

The govenrment will conintue to be very a important actor, especially CMS,  setting payment policy that will impact the behavior of all stakeholders.  However, I believe the era of prescriptive government direction of the IT agenda has ended.  Provider organizations are begging for an outcomes focus, instead of a process focus.

Where will the next innovations come from?   

How about the large incumbent HIT vendors?   Despite rumors to the contrary our major healthcare IT vendors are well meaning and not spending their time information blocking.  They are devoting their resources to creating software which adheres to the thousands of pages of regulations introduced over the past few years.  One major vendor noted that their programming staff is already booked for the next 32 months just to ensure compliance with existing regulations.    The small amount of free bandwidth that incumbent vendors had reserved for innovation has been co-opted by regulation.

How about startups or high tech companies that have a startup mindset?   Startups, such as those making population health/care management, decision support, and consumer facing apps likely have more time to focus on innovation than incumbent EHR vendors maintaining certified EHRs.   Many of these startups lack domain expertise in heatlhcare processes, so they may not produce the products and services the marketplace really needs.      However, that’s ok, since out of many failures often comes one great success.   I think we need to watch companies like Apple, Google, Amazon, Facebook, and Salesforce for important healthcare innovations.

How about provider organizations?   Some academic healthcare systems have dedicated innovation resources and they will continue to lead important work.  However, provider organizations are faced with the compliance/enforcement side of the same regulatory expansion that is consuming the incumbent vendors.    Most provider organizations will devote 100% of their IT resources to operations and compliance.

So, it’s an edgy prediction, but I beleive the next 5 years of healthcare IT innovation will belong to the private sector, to companies we’ve not yet heard of and companies outside the usual healthcare IT mainstream.    The incumbent vendors may be able to crowdsource and leverage the resources of these innovators, as Athena will do with the More Disruption Please program and  Epic will do with its app store.

At BIDMC, we’ve launched our own crowdsourcing program and we’re increasingly dedicating resources to innovation.   We’ll continue our collaboration with numerous private sector companies, serving as a learning lab to test new ideas.    

In my next 20 years, I hope to oversee innovative work on social networking communication applications, patient-facing mobile applications, population health analytics with workflow tools, and cloud-based healthcare IT services.    I turned 54 this month.   I’m hoping at 74 that I can reflect on 40 years in New England and say that my efforts have made a difference.