Unity Farm Journal - First Week of October

The drought has taken its toll on the Fall color, with leaves going from green to brown then dropping off the trees.   The mornings are crisp - in the 50’s and the afternoons barely reach 70.   The shadows are long and the hoop house loses sunlight at 3pm.   The lettuces and spinaches are thriving in the early fall weather and the furry animals relish the cooler climate.

Each week is filled with harvest work and the effort to move Unity Farm Sanctuary forward.    We’re finishing the inspections and well testing of the adjacent property this week and hopefully will progress to a formal purchase and sale next week.    I’m already planning the new trails between the two properties - I’ll call them the Pine Loop, the Pond Trail, and the Coyote Path.    When I’m done, the combined farm and sanctuary will have 3 miles of trails.

The Sanctuary will have an educational mission with an animal care training area, a mushroom cultivation area, a flower CSA, a farmer winery/cider demonstration area, and sustainable agriculture instruction classrooms.

The new property will have 3 new paddocks and a 5 stall barn.   We’re already begin contacted by folks who have animals needing new homes.   Likely our first addition will be a pair of donkeys - one age 12 an one age 20.   They can live 30-50 years with the right conditions.   We’ve been offered sheep, alpaca, and goats.   We’ve thought about our ability to deliver the companionship, medical care, and quality of life needed by each of these species and we’ll probably avoid sheep, which bring different parasites and bacteria to the farm than the existing inhabitants.

The tomatoes are gone and the lettuce/spinach/carrots are thriving, but only in our beds with micxospray irrigation.   Those in outside beds are struggling since the 3 month period with virtually no rain has turned our once fertile river bottom soil into hardpack.  Here’s a New York Times article about our region

This weekend we’ll crush 250 pounds of Cortland and McIntosh apples for hard cider.  Next weekend we’ll do the same.    The following weekend, we’ll host a group of IT leaders and host the local 4H club to demonstrate cider making with just 120 pounds of apples.    This will be the last year we use a hand cranked apple scratcher to create Unity Farmhouse hard cider.

From now on, a 2 horsepower stainless electric grinder will enable us to mill 1000 pounds per hour.

For next season, I’ll likely build a 60F climate controlled fermenting area with enough tanks to support our goal of 300 gallons of production from 5000 pounds of apples.   We’ll still be a small producer but we’ll be efficient.

Social Media Guidelines for our Clinicians

We recently published this guideline at BIDMC based on the input from a multi-disciplinary working group.   I thought it might be useful to share with the community, since many healthcare organizations are at the early stage developing social media policies.


1.  Why do consumers interact with an organization’s social site?

In general, there is a perception gap between the reasons consumers interact with companies on social sites and why the companies think they do. (Source: IBM Report: From Social Media to Social CRM)

After discounts and purchases (not applicable to BIDMC), consumers ranked reviews and product rankings, general information and exclusive information as the top reasons they follow a company.

Companies ranked learning about new products, general information, sharing opinions, and reviews and product rankings as the top reasons they think consumers follow them on social sites

Reviews and rankings are important to consumers, so we track and respond to all reviews/messages we receive. The reviews are also a great way to capture feedback about patient experience on an ongoing basis.

We receive reviews on all our social media sites. Some are informal, like a tweet. Some are formal reviews, like on Facebook, Yelp, Google+, etc. BIDMC monitors all sites 24/7 using a social media dashboard.

To maintain our integrity, BIDMC follows the same social media guidelines as the universal online community. This means:

We do not delete negative posts. The only thing worse than ignoring a negative comment is deleting it.  It only serves to anger the patient/consumer more and give them reason to react by telling ALL of their ‘friends’ on social media about their experience. The exception is when a negative post uses hateful, obscene or discriminatory language.

We do not ask for feedback or reviews from patients. Sites like Yelp have rules. One among them: “Business owners should not ask customers to write reviews. Review sites work because consumers voluntarily write reviews.” This is why Yelp, Healthgrades, etc. are able to provide consumers with as much trustworthy information as possible. Research has shown that when the consumer realizes that reviews and feedback have been solicited or influenced, they stop using it.


2. How do we respond to reviews?

We respond to all messages—both praise and criticism.  When we receive a complaint:
We respond ASAP.

We don’t make excuses.  (“We were short staffed” or “It was an unusually busy day”)

We apologize for the experience.

We try to take it offline as soon as we can. We send a direct message to the reviewer.

We resolve the issue. We immediately connect with Patient Relations to alert them to the complaint so they can follow up.

3. Why do we apologize?

We have had a few instances when a physician has felt strongly about apologizing. Some physicians are of the opinion that apologizing is an admission of error which could lead to lawsuits.

We believe that enhancing communication reduces malpractice assertions, not increases that.

The Marketing team along with Patient Relations has established a process to manage complaints/negative reviews. Our standard response in most cases is: We are sorry that your experience didn’t live up to the high standards we set for ourselves. We will forward your message to our Patient Relations team. If you’d like to contact them directly, please call ....

4. What does a physician need to be aware of BIDMC’s social media policy?

There is risk associated with the use of social media because any content posted can reflect unfavorably on the physician as well as on BIDMC. A post conveys information about the user’s personality, values, priorities, etc. To avoid errors and prevent risks, BIDMC has created a set of guidelines to help our physicians navigate the world of social media. The full policy is available on the portal. Here are some highlights:

Physicians cannot accept friend requests from patients.
If a physician engages in a discussion about the hospital on a social site, she/he should disclose that they work at BIDMC. On personal feeds, if discussing BIDMC, clarify that the posts do not express the views of the hospital.
Physicians cannot offer health care advice on social sites.
Physicians must respect and follow HIPAA requirements. She/he can never disclose information about a BIDMC patient.
She/he cannot endorse products on social media
Physicians must never disclose proprietary information about BIDMC.
BIDMC does not allow individual departments to open social media accounts. On rare occasions, Twitter or LinkedIn accounts are allowed. The request to open a social media account must be approved by the Social Media Policy Committee.

Unity Farm Journal - Fourth Week of September 2016

It’s the first week of Fall and leaves are beginning to drop.   The drought of Summer has stressed all the trees and they are going dormant early.    We’ve done our best to keep our orchards thriving, but the Apple harvest is about half the usual quantity as well as a few weeks early.   Last year our Macs and Red Delicious had the desirable sugar levels (15-20%) in mid October.   This week, they were already at 16%, so we harvested.    We’ll be pressing cider over the next two weekends and begin the weeks of fermentation for our 2016 vintage.  

We’ve harvested the last of our peppers, tomatoes, and eggplant.   This weekend we’ll have night time temperatures in the 30’s.    The lettuce, spinach, and carrots will happily thrive at those temperatures, but the more tropical plants will literally melt.    Within the next two weeks we’ll begin our first Fall lettuce harvests.   When you’re an organic farmer, using heirloom seeds and all natural growing techniques, you see a lot of variation.   Sometimes our peppers are very “Micky Mouse”

This week we moved forward on our efforts to create the Unity Farm Sanctuary, hoping to double the size of Unity Farm.    If all goes well, we will close within 90 days.   Between now and then, we'll plan how best to host additional animal rescue operations and education as part of our non-profit charitable mission.     We 'll consider adding an aviary for bird rehabilitation and a clean area for veterinary procedures.  

The past 5 years have been about creating the infrastructure to support farm operations for Unity Farm LLC.   The next 5 years will be about creating the people, processes, and workflow to support Unity Farm Sanctuary Inc.    I’ve started a new notebook - Unity Farm Sanctuary Projects and we’ll set priorities during our next few months, then begin taking action once ownership is transferred in December.

Reducing my Digital Burden

Last weekend, I started a process that some may consider regressive.   I began deleting my social media accounts to improve the signal to noise ratio in my life.

10 years ago I wrote about the importance of social media and building networks of colleagues, collaborators and relationships.

During that decade our social norms have changed to the point that we walk off cliffs, text while driving, and document every microsecond of our lives on devices that have become the centerpiece of our waking hours.

The problem has gotten so profound that Google has introduced artificial intelligence technology to respond to messaging for you - “LOL”, “cute dog”,  “a movie at 7pm is great”.

Here’s a twisted idea - maybe my wife and I should sign up for the new Google service and just let her account speak with my account while we go for a quiet walk in the forest.   Problem solved :-)

What have I done to begin cleaning up my digital life?  

1.  I have deleted my LinkedIn account and its thousands of incoming messages.   There are 4 John Halamka profiles left - two of which are fraudulent and two of which belong to my father who passed away 3 years ago.

2.  I have deleted my Plaxo account.   Plaxo seems to have faded in popularity and usefulness, so maybe no one will notice

3.  I have deleted my Google+ account.  Although it was an interesting idea, I found Google+ most useful to communicate with Google employees.

4.  I have deleted my Microsoft Healthvault account.   I no longer find it useful middleware for communication with my providers.

5.  I have blocked all newsletters from Constant Contact and other “business spammers” from my inboxes.

What have I kept - my email accounts (one personal, one business), my ability to receive texts, my blog,  my Twitter account (which is automatically linked to my blog via an agent) and my Facebook account.   Nothing more.

I had planned on deleting my Facebook account but my wife noted that our farm communications depend upon reaching my network of contacts, so she will continue to update my Facebook network.

The end result is that I have a digital clean slate - no pending inboxes, notifications, or queues.   I can go through the day not staring at my phone or receiving a cacophony of chirps/beeps/dings/bells/chimes.   I can have conversations without guilt.  I can mentor people without losing my train of thought.   I can return to my usual work pattern of deep focus rather than superficial bursts of concentration.

Some may accuse me of losing touch or suffering a loss of agility in my 54 year old mind.

Some may say that continuous partial attention is adaptive to the interconnected global economy and that we all should adopt a communication style similar to “Spock’s Brain” -  constantly responding to every input like an automaton.

I have told my staff in the past that when I’m an impediment to innovation, it’s time for me to go.    I do not think this streamlining of my digital life is a sign that my losing my passion for improvement.   Instead, I think I’ve changed my definition of improvement.   When I first started using a Blackberry 850 in 1999, it empowered me to leave my desk and respond to incidents while traveling.    A two way pager improved my productivity and mobility.    Today we keep our digital devices on our nightstands and reflexively check for communications every 30 seconds (or more).   They have become an addiction that makes us work more hours but not necessarily more efficiently.

I completely understand that the way we work will change over time, increasingly moving to bursts of virtual communication.   At the same time, I know that innovation requires a deep dive to solve complex problems.    By shedding my digital burden, while keeping a minimal number of communication modalities, I can  balance my service to the community of stakeholders and the hours needed to deliver tangible products/services.

Unity Farm Journal - Third Week of September 2016

The nights are beginning to cool down to the 40’s and we’ve doubled up on the straw in the pig barn in addition to tucking them in each night with 3 fleece blankets.   In a few weeks we’ll move them from the Summer Pig Cottage (shaded/east facing) to the Winter Pig Palace (sunny/south facing) and given them their cold weather quilts for sleeping.    It’s hard to imagine the farm without the pigs.  Like dogs and geese and they are intelligent, emotionally responsive companions that really brighten our days.

The drought continues and we’ve had only half an inch of rain this month.   The apples are maturing but the crop is very small.   This weekend, I’ll do refractometer measurements on the Macintosh and other early apples to figure out when to harvest them.   I’m hoping for a sugar content over 15%.    We’ll likely press cider for fermentation once in early October and again in early November.
Much of the September farm time has been spent converting our summer crops (see below) to fall crops, clearing raised beds and the hoop house for lettuce, chard, spinach, carrots, and beets.  The trick is to get relatively large, robust plants before the days get too short and the weather grows too cold.    If the plants are resilient enough, they’ll continue to grow even in December and January.   Our compost screening machine has been working overtime, making the hundreds of pounds of finished “llama beans” that we use to fill our growing areas.

Unity Farm continues to be a rescue site and this week 3 bantam roosters will arrive to supplement our 100 chicken community.   Everyone gets along and the barnyard literally buzzes with activity every morning when 100 chickens (including the frizzles below), 100 guinea fowl, 7 geese, 6 ducks and 2 pigs get together for the morning feeding.

Early fall is my favorite time of year.  Crisp mornings give way to warm but not hot afternoons.   The humidity is beginning to fall.   The hard work of summer ends with the harvest and preparation for 6 months of cold weather ahead.    As I’ve said before, running a farm is joyful chaos, but the seasonal expectation of indoor downtime is something we look forward to.

Clarifying Certification Requirements for Hospitals

With all the changes happening to Meaningful Use, Quality Measurement, and MACRA in 2016, I’ve been asked many questions by many organizations to help them plan for the future.

As I’ve said many times, one of the great challenges we have is that the 2015 Edition final rule has an enormous scope extending beyond Meaningful Use with the notion that it can be coupled to every government healthcare IT program.    Standards needs to be based on requirements and specific use cases with little optionality, so creating a broadly scoped rule before the use cases are known just doesn’t work.   Although it is my hope that the tight coupling of the 2015 Edition final rule to various programs will be eliminated eventually,  it is important to understand what certifications are needed for what programs in 2016, 2017 and 2018.

For example, all current BIDMC systems are certified to the 2014 Edition.    Will we be able to participate in government programs in 2016 using the 2014 Edition Certification?  Yes!    Will we be able to participate in government programs in 2017 using the 2014 Edition Certification?  Yes!    Only in 2018 will we have to be certified to the 2015 Edition and we can all hope that the certification concept is revised before then.

Here’s an example of the actual language in regulations illustrating certification requirements.  Please find below rule text excerpts and citations to the Hospital Inpatient Quality Reporting Program’s EHR certification requirements for electronic clinical quality measures (eCQM) reporting.

For the CY 2016 reporting period (FY 2018 payment update), use the 2014 or 2015 edition:

From the FY 2016 IPPS final rule (80 FR 49705-6):

“In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24587), we proposed to continue the requirement for hospitals to use CEHRT 2014 Edition when submitting electronic clinical quality measures for the CY 2016/FY 2018 payment determination. However, in response to comment suggesting that hospitals be allowed to report using either the 2014 or 2015 edition of CEHRT, we are finalizing a modification to our proposal such that, for CY 2016/ FY 2018 payment determination reporting of electronic clinical quality measures, hospitals can report using either the 2014 or 2015 edition of CEHRT.”

For the CY 2017 reporting period (FY 2019 payment update), use the 2014 or 2015 Edition:

From the FY 2017 IPPS final rule (81 FR 57170):

“After consideration of the public comments we received, we are finalizing that hospitals must report using EHR technology certified to either the 2014 or 2015 Edition for the CY 2017 reporting period/FY 2019 payment determination (not subsequent years) as proposed.  We also refer readers to section VIII.A.10.d.(5) of the preamble of this final rule, in which we finalize alignment of this policy in the Medicare and Medicaid EHR Incentive Programs.”

For the CY 2018 reporting period (FY 2020 payment update), use the 2015 Edition:

From the FY 2017 IPPS final rule (81 FR 57171):

“After consideration of the public comments we received, we are finalizing the required use of EHR technology certified to the 2015 Edition for the CY 2018 reporting period/FY 2020 payment determination and subsequent years as proposed. We also refer readers to section VIII.A.10.d.(5) of the preamble of this final rule, in which we finalize alignment of policies in the Medicare and Medicaid EHR Incentive Programs.”

I hope providers and developers find this useful.    In the next few years, we can hope that the entire QRDA quality reporting standard is replaced by a FHIR implementation guide or at the very least, the need to use QRDA Category 1 (individual patient data submissions) is eliminated.

Unity Farm Journal - Second Week of September 2016

Hurricane Hermine came and went, dropping only 2/10ths of an inch of rain on the drought parched soil of Eastern Massachusetts.   Although we had 20 mph wind gusts, none of the stressed trees were knocked over.

We’re continuing to irrigate our crops using our 60 zones of drip irrigation, while trying to preserve the well.   We’re praying for rain.

We’re always learning at Unity Farm.   This week’s question - can a pig get cyanide toxicity from eating peach pits?    Each week we receive the discarded fruit and vegetables from Tilly and Salvy’s farmstand, feeding them to the pigs, poultry and alpaca.    Hazel Marie, our 200 pound pig (picture below) loves to crack open the peach pits with her strong teeth and eat the kernals inside.    I’m told they are bitter, so the behavior seems strange.    Of concern is that peach pit kernels contain cyanogen glycosides in the form of amygdalin.   From all my reading, it appears that Hazel would have to eat a dozen or more peach pits at a time to have a problem.  Nonetheless we’ll stop feeding stone fruit to the pigs since the last thing we want is piggy peach poisoning (ICD10 T62.2X1A  and T65.0X1A)

Unity Farm would best be described an organic animal community.   Although rescued animals are added on an ad hoc basis (we were called to rescue a chicken blown from its home by the Hurricane), all the others have been added throughtfully with a  introduction period in an isolated barnyard pen before release.    The end result is that everyone gets along.  Here’s a typical barnyard scenne - the pigs, chickens (including bantams) sharing dinner together while a baby alpaca snacks in the distance.

This week we harvested the last of the tomatoes and we’ll soon finish up the peppers and eggplant, leaving us with 15 beds for lettuce, spinach, and carrots.      We’ll be crushing apples for hard cider soon, although its been a tough year for apples with the unexpected spring freeze and the summer drought.   Then again, the joy of farming is working with the animals and plants throughout the seasons, responding with agility to whatever nature brings.

This weekend we’ll be bagging compost for sale, and checking our forest plantings for ginseng growth.   We planted 15 beds of ginseng in isolated forest locations and if they were successful now is the time to check for their red berries of late summer.    I have a feeling the drought might have diminished our ginseng experiments but we’ll know more soon.

The Joy of Mentoring

Since 2016 is the 20th year I’ve served as CIO, I’ve given a great deal of thought to the various careers I’ve had and the roadmap for the 20 next years of my working life.

In my late teens and 20s I was an entreprenuer running a 35 person software company while doing my medical and graduate school training.   I was also a winemaker, home builder and engineer.

In my early 30’s I was an Emergency physician, software coder, and data analyst.

In my mid 30’s as a CIO, I focused on architecture, high reliability computing, and centralization of IT service delivery

In my early 40’s, I focused on disaster recovery, interoperability, and educational technologies

In my mid 40’s, I focused on security, national policy, and IT industry leadership.

In my early 50’s, I’ve focused on social networking, mobile, analytics, cloud and innovation

So what will my mid 50’s bring?    Although in my previous incarnations, I’ve written code, built hardware, and shaped architecture, it feels that this next stage of life should be about mentoring the people who will eventually replace me.

Mentoring from those who came before me (Sensei is a Japanese honorific term that is literally translated as "person born before another”) has always guided my path.   My parents were my earliest mentors. In my college years I worked for physicist Edward Teller and economist Milton Friedman, who had a great influence on me.   My undergraduate advisor was Condoleezza Rice, a remarkably talented Stanford junior faculty member at the time, just 7 years older than me.   In my later years at Stanford, I lived with Dr. Fred Terman, the “father of Silicon Valley”.     In my entreprenurial days I had the opportunity to interact with Hewlett and Packard, Jobs and Wozniak, Bill Gates and Paul Allen.   My medical school advisors were J. Michael Bishop and Harold Varmus, who won the Nobel Prize.  In my BIDMC career, I’ve been mentored by various professors from Harvard Business School,  CEOs of publicly traded companies, and billionaire investors.

It’s now my time to pass along all my experiences through teaching, writing, and being available to all those who want to seek my help.   My role as Harvard professor is to accelerate innovation by reducing barriers and empowering those who can orchestrate change.   My role as BIDMC System CIO is to harmonize policies/technologies and resolve conflict whenever it arises.    My job is neither to command/control nor micromanage, but to offer strategic guidance and help implement tactics when asked.   I try to be a servant leader and embrace a “set of practices that enriches the lives of individuals, builds better organizations and ultimately creates a more just and caring world.”

I will strive to be a mentor in two worlds

1) running a healthcare IT innovation lab at BIDMC that supports a standard process for bringing ideas to real world production systems in a live clinical environment

2) running an organic farming and sustainable agriculture lab at Unity Farm that educates the community about raising healthy animals and plants with little more than your brain, two hands and the forces of nature.

In the coming months, I’ll write about the steps I’m taking to develop both nuturing environments - formalizing the mentoring work I first outlined three years ago in The Toad and the Snake post  and establishing the non-profit Unity Farm Sanctuary Inc, a charity providing agricultural education for the greater Boston community.

The past 20 years have been great.   The next 20 years will be even better because people smarter than me will be taking on the challenges ahead, I’ll just be clearing a path for them.

Unity Farm Journal - First Week of September 2016

Tropical storm Hermine is approaching New England this weekend and we can only hope we get some drought relief without too much wind.    The ferns in the forest crunch like potato chips and the soil around the farm has become hard pack.   All the alpaca compost we’ve mixed into our growing areas helps retain moisture, but with months of little rain, every non-irrigated area is drying out.

All of this dry weather has increased predator pressure on the farm.    Coyotes now visit every afternoon and we’ve lost a few chickens.   With very limited water and food sources in local forests, the farm has become their best source of sustenance.    Over the labor day weekend, I will listen closely for every guinea fowl alarm and run toward the disturbance as fast as I can.    I’m a vegan, a peaceful person, and have complete empathy for the food chain.  However, if our animals continue to be threatened, we may have no other option but to consider hiring a coyote removal specialist.

Luckily, we’ve not lost any guinea fowl, ducks, or geese.   The geese are very social but do not easily interact with a 6’2” person standing up.   Here’s a glimpse of some quality time with geese at their level.

We’ve been doing Fall planting and that means all the raised beds have to be refilled with alpaca compost when the spring/summer plants are removed.    Since we process 20,000 pounds of alpaca manure into compost every year, the alpaca compost screener we designed is working overtime.    Peter, who helps us with farm chores, designed a new addition to the compost screener to automatically deflect rocks and sticks away from the screened compost.    We call this new device, “The Peter”.   Here’s a photo

This weekend we’ll continue our preparations for winter.   Although it seems strange to touch up paint/varnish/stain, trim trees, add gravel to roads, patch hoop house plastic, and maintain all the cold weather equipment during the first week of September, “winter is coming”.    The farm’s 15 acres have to be ready.