Unity Farm Journal - Fourth Week of October 2016

After two weeks of international IT collaboration, I’m returning to the farm tomorrow.   Kathy and I have been in constant contact despite the 6, 12 and 17 hour time shifts during my travel.

What has Kathy done in my absence?

1.   A few baby guinea fowl showed up in the driveway after being hatched in the forest and then chilled in rain/freezing temperatures (did I mention Guinea Fowl are horrible parents).   We immediately put them in the brooder but only 1 survived.   We named him Rambo.   He refused to eat because he was so focused on searching for his brothers and sisters.     Kathy gave him an instant family of freshly hatched chicks (pictured below) and now he’s eating like a horse.   We’ll move the entire group to a mini coop inside the main coop when I return.

2.  We’ve had 5 inches of rain during my travels so our mushroom farm has thrived.   Kathy has harvested 100+ pounds of Shiitake and has filled a stack of produce bins as tall as she is.   Here’s what happens to inoculated oak logs when they’re soaked with Fall rains and  given moderate temperatures.

3.  All the bantam chickens and roosters new to the farm have established their pecking orders and found their territories.  Kathy has kept them healthy and happy.   We’ve not lost a single bird to predators while I’ve been gone.

4.  Before I left I cut a road from the barnyard to the new aviary area and around the back of the alpaca paddock to the edge of the new sanctuary property we’re acquiring next door.   In my absence the gravel for that road arrived so we now have a new area to drive over with farm equipment.    I've called it Sanctuary Road.

5.  When I left, the trees were just turning and the forest was still dense with growth.   Kathy has watched the leaves fall and has been sweeping the ponds of leaf matter daily

6.  Although the aviary was nearly done before I left, the hardware cloth shipment arrived and Kathy hired a local contractor to install the wire.     We'll create a small shelter inside the aviary and then be able to host various species as soon as our permits arrive.

7.    Uneaten hay, mud, and excess rain combined to create a kind of quicksand in the girl paddock.   During my absence a local farm hand used our front loader to clear out the paddocks.   The alpaca are thrilled to have a flat, firm, dry place to sit.

This weekend I’ll be busy doing animal care - trimming alpaca toenails, running with the dogs, giving the pigs the belly rubs they’ve been missing.   I’ll be crushing and fermenting 500 pounds of apples.     I’ll be racking the cider I fermented before I left.   The work on the farm is invigorating and I will not miss sitting in economy seats while the person in front of you leans back all the way

New Zealand Can Lead Healthcare IT

I’ve been in New Zealand this week, meeting with government, academic, and industry leaders to discuss the IT challenges ahead - social networking-based teamwork for health, mobile applications, precision medicine analytics for decision support, and cloud computing all within a framework of protecting privacy.

I believe that New Zealand has a unique opportunity to leapfrog the rest of the world with healthcare IT breakthroughs that show the rest of us what is possible from a 4.5 million person learning lab.

Why?

The perfect storm for innovation requires alignment of technology, psychology, and implementation.

New Zealand is divided into 20 District Health Boards which improve the health of their populations by delivering high quality and accessible health care.

The District Health Boards remind me of the County Council system in Sweden, which in my opinion is the best healthcare delivery model on the planet.   Although District Health Boards are funded by the central government, they have flexibility to innovate and there is complete alignment between investment and outcomes.   If District Health Boards spend $1 on healthcare IT and save $1.50 in care costs, they keep the surplus.   Historically, in the US, if I spent $1 on IT and reduced costs by $1.50, the private insurers would benefit, not the provider organizations.    Countries with socialized medicine and local implementation organizations align costs, benefits, and regional awareness of the key problems to be solved.

I met with leading IT thinkers, innovators and folks at the highest levels of government (photo below is the "Bee Hive" Parliament).   The executive and legislative branches are completely comfortable with the idea of creating a countrywide database that incorporates clinical data, financial data, social determinants of health, genomic data, social service data, and judicial system data.   Instead of sending 5 cars to a person’s driveway to deliver services from 5 different government agencies, every government official wants a coordinated program of service delivery based on bringing well being to families.

New Zealand has many advantages - a national healthcare identifier, a common privacy policy, a robust economy,  a relatively small population, and a geography that can be traveled by air from tip to to tip in 2 hours.

The people of New Zealand are remarkable - they are friendly and approachable in ways that are subtle.   For example, I walked into the airport and to my gate without a boarding pass.   The folks at the gate happily printed my paperwork without question.   The level of anxiety/fear is low and the political climate is such that the liberal and conservative extremes are not that far apart.

The infrastructure for internet connectivity is good and the number of local developers/tech experts is high.

New Zealand has the technology for data capture/exchange, a desire to maximize quality/safety/efficiency and District Health Boards to implement it.   District Health Boards operate hospitals and fund primary care in each area so there is a single point of accountability and authority per region.    I met with District Health Board leaders in Auckland, Wellington, and Christchurch, so I can confirm they are dynamic, motivated, and well informed.

The next year in the United States is likely to be politically challenging and lacking enablers such as a single healthcare identifier to execute any bold national program of big data aggregation.    Finally, every person in New Zealand I spoke with felt that individual privacy, although important, was not an impediment to building a large database for societal good.

So watch New Zealand.   2017 is the year they can lead the world.   With government, industry, and stakeholder alignment they can set an example for us all.

Unity Farm Journal - Third Week of October 2016

I’ve been in China this week, so Kathy has been running Unity Farm.    As usual, the farm continues to be an ever evolving and exciting place.  Here’s a typical email from her

“Many visitors were here today.   Our young intern was here helping out for an hour, then at 4:30pm someone dropped off a 5 year old pair of hens, then a person dropped by to spin honey from their hive.    You never know what each day will bring”

She’s received several more rescue animals this week and she’ll decide which animals which will live permanently at Unity Farm and which will be placed at other farms.    I’m working on a business plan for the Unity Farm Sanctuary, having learned a great deal about grants, fund raising, and the sustainability of sanctuaries from reading other’s experiences

We’ve been expanding our capabilities to receive an increasingly diverse array of species, such as birds that cannot be released directly into the wild. Here’s a picture of the new aviary we’re building.  I’ll finish it next weekend after I return from my travels.     We’ll be ready for various rescue birds once we receive our state license to host them.

Kathy has been tending our cider fermentation and the 2016  vintage is shaping up to be a very flavorful, well balanced product.     We have 500 pounds of apples left in the cooler and I’ll press them when I return.   Here's our new growler design.

We’re always learning about the land and the history of the landmarks we’ve discovered on the farm.   A few years ago, while clearing trails, I found a slate gravestone sitting in a grove of old cedar trees labeled

“James Bullard”
Died June 30, 1828
Age 66

Who was James Bullard?   He was “Johnny Tremain”

When I was an elementary school student, I read the story of a fictional 14 year old living at the time of the revolutionary war and his impact on those events.   James Bullard was 14 years old in 1776 and he tended the gunpowder for the minutemen in the  Sherborn area.    On June 30, 1828 he had “apoplexy” and died instantly at a spot not far from our barn.   Apoplexy could be anything from a heart attack to a stroke.   At his funeral all the town families toasted rum in his honor, then shortly thereafter decided  to ban all alcohol from the town.    When James died, so did alcohol consumption in the town.    Here’s the story of the his gravesite at Unity Farm as written by a member of the Sherborn Historical society.

This weekend, I’ll be in New Zealand and Kathy will plant the 2017 garlic in our large outdoor beds.   I’ve promised that she can take a vacation when I return from my October travels.   Some people say they look forward to retirement so they can travel.   I’m not sure what retirement is, but I can only hope the travel is less!

The Quality Payment Program Final Rule

Many people have asked me to review the Quality Payment Program final rule, released on October 14, 2016.

Several summaries have already been written but your best bet is to rely on the CMS Quality Payment Program website at https://qpp.cms.gov

Yes, the rule is still complex - over 2400 pages, of which more than 50% is the mandated response to comments made on the proposed rule.  The good news is that CMS has been very responsive to feedback, creating a transition plan for adoption, reducing the number of criteria and extending the timeline which enables iterative learning before large scale implementation.

Under the Quality Payment Program, clinicians have two approaches to choose from for reimbursement:  the Merit-based Incentive program (MIPS) and Advanced Alternative Payment Models (APMs).

The Merit-based Incentive program (MIPS) is a new program for certain Medicare-participating eligible clinicians that makes payment adjustments based on quality, cost,  practice improvement, and technology adoption while consolidating components of three existing programs—the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals.  MIPS focuses on quality (both a set of evidence-based, specialty-specific standards as well as practice-based improvement activities),  and use of certified electronic health record technology (CEHRT) specifically focused on interoperability and advanced quality objectives.

In the final rule's technology area, called Advancing Care Information (which replaces Meaningful Use for physicians), CMS reduced the number of measures from 11 to 5 .   CMS recognizes that technology, infrastructure, physician support systems, and clinical practices will change over the next few years, so over reliance on a highly prescriptive and broadly scoped certification rule must be avoided.

Think of MIPS not as four separate categories (quality measurement, cost control, practice improvement, and wise use of IT) but as a single program focused on rewarding clinicians for improving quality and penalizing clinicians for non-participation.   There are only a few ways to change clinician behavior - pay them more, improve their satisfaction and help them avoid public humiliation (like poor quality scores posted on a public website).  MIPS pays them more, consolidates multiple other government programs, and provides flexibility to give clinicians every opportunity to make their quality scores look good.

Advanced Alternative Payment Models (APMs) were created to gradually evolve the US healthcare system from volume-based to value-based care.   Instead of rewarding clinicians for ordering more tests, APMs align incentives to reward wellness.   APMs are not a mechanism to deny patients access to appropriate care.  Instead they incentivize clinician to deliver the right care, at the right time in the right setting, hopefully achieving good outcomes at lower cost.   They involve taking downside risk - if you spend too much, your income is reduced, aligning risk and reward for spending healthcare dollars.

There are many different kinds of APMs - the Shared Saving Program, Medical Home Models, and episode payment models for cardiac and joint care.

CMS is exploring development of a voluntary Medicare ACO Track 1+ Model for ACOs currently participating in Track 1 of the Shared Savings Program or ACOs seeking to participate in the Shared Savings Program for the first time. It would test a payment model that incorporates more limited downside risk than is currently present in Tracks 2 or 3 of the Shared Savings Program.

Which approach should you choose - MIPS or APMs?   That depends on the size of your practice, the tools you have available to support care management/population health, and your experience with different payment models.    For a comparative analysis of the MIPS and APM programs see  https://qpp.cms.gov

In previous posts, I lamented the impact of the proposed rule on small practices, the linkage to the 2015 Certification Rule and the burden of measurement/reporting.  Many organizations reported similar concerns.

What did CMS do in the final rule?

They

(1) created a transition year with an iterative learning and development period in the beginning of the program.  This is described in detail on Andy Slavitt’s blog as the “pick-your-own-pace approach”  
(2) adjusted the MIPS low-volume threshold ($30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients) exempting many small practices
(3) established an Advanced APM financial risk standard that promotes participation in robust, high-quality models i.e. creating Track 1+ which reduces overall downside risk
(4) simplified the  technology requirements and offered partial credit for progress on technology goals
(5) established of Medical Home Model standards that promote care coordination.

The rule is a final rule with comment – which means that there are numerous areas in the rule where CMS is seeking comment to inform  future rule-making, and that comment period is open for 60 days. Seek out those sections and send CMS comment letters.

This year I’ve spent time in the UK, Denmark, and China, so I’ve watched how a single payer system and a more uniform, government administered approach works for society.    Although it may be that the US will evolve to a more uniform healthcare delivery system over time (i.e. a few decades) there is no way such wholesale change is politically  possible in the short term among the heterogeneous stakeholders of the United States.

Think of the Quality Payment Program as the beginning of a journey.   Some of it will work and some of it will not.   Some reimbursement choices will be expanded and others discontinued.   As long as clinicians are given flexibility along the way, and the overall burden is kept at a manageable level, I’m willing to pilot some of these programs and see how it goes.     More to come as we get into the details of EHR certification (just the limited components we need for APMs), compute quality measures, and build analytic tools   CMS is listening and I thank them for it.

Unity Farm Journal - Second Week of October 2016

Despite my international travels this week and next, the farm waits for no one.   150 creatures need food and warmth.   The buildings and infrastructure need tending.   The vegetables and fruits need harvesting.      Between Denmark and China, I returned to Boston for day to ensure everyone was healthy and happy.

The temperatures dipped to 31F and I tucked the pigs into their quilts, shut the barn door, and let the panel heaters raise the temperature of their pig palace by 10 degrees F.

The chickens and guinea fowl generate so much body heat that their coop was a cozy 50F

The alpaca and the Great Pyrenees love the cold so they basked in the dry evening not inside the barn, but under the stars in the barnyard.

The consistently cool temperatures have brought out all the colors in our swamp maples, oaks, and poplars.  Unity Farm is now at “peak”.  Here’s a view of the farm lane along the meadow.

Before I left for Denmark, I used the Terex front loader to clear a 12x24 foot area of the forest behind the barnyard for the aviary we’re building.   Our animal rescue activities include birds that need to be isolated or kept safe from predators.  The base of the new structure is 1 foot underground so no creature will burrow into it.    We’re applying for the appropriate state licenses to host pheasants and other rescue birds.

Our apple pressing efforts this year have been very successful with nearly 1000 pounds processed using our manual grinder and press.    The first batches are done fermenting and we’ve racked them into fresh sterile containers for secondary (malolactic) fermentation over the winter.

Our farm sanctuary planning continues and we’re designing the integration of a public farm educational and animal rescue center with the existing Unity Farm barnyard, orchard, and trails.   It’s an exciting time and we think 2017 will be a pivotal year for our activities.

While I’m away, Kathy will have part time help a few hours a day to do the tasks I would normally do early mornings and evenings.    She’ll harvest our mushrooms, lettuce, and remaining apples.   She’ll ensure all the animals return to their protected shelters at night.    She’ll keep the farm a vibrant place.   She's amazing.

The farm beckons in the Fall, but  IT duties call and there are miles to go before I sleep!

Dispatch from Denmark

Today I’m in Denmark speaking at a yearly national healthcare IT conference.  

Denmark is a remarkable country of 5 million people with a robust social support system.    Healthcare is provided for life as part of being Danish.   If you lose your job, generous unemployment benefits provide for the ongoing well being of you and your family.    Income inequality is among the lowest in the world (see the world mapped by income inequality below)

When people gather together in Denmark, there is a sense of common purpose and shared experiences.   The Danish call this “hygge” or coziness.

I spoke about the experiences of the Meaningful Use program, the evolving US reimbursement system, and the quest for innovation - especially in the areas of social networking for healthcare, mobile, analytics, and cloud hosting.

As I travel the world, I find the most societies are struggling with the same problems - how to improve healthcare quality while reducing cost, how to enhance safety and efficiency with technology, and how to improve the patient experience.

Technology is rarely the rate limiting step.   Instead the primary issues are workflow redesign and process improvement.

While in Denmark, I heard that government planners proposed implementing automation to save money by eliminating medical secretaries and other team members who would have shared the burden of data entry.   I explained that this would be "penny wise and pound foolish".   In the US,  40% of clinicians want to quit because they no longer practice at the top of their license, spending half their day on data entry.  Rather than expect a return on investment from staff reductions, a better approach would be to spread the work of new digital tools across a team of caregivers/support staff enabling all clinicians to be more productive doing direct patient care.

Denmark has taken a leadership role in many areas.   They have a single lifetime identifier for healthcare.   They have a nationwide registry of medications.    They have a single uniform consent and privacy policy for the country.   The US needs to follow their example in these areas.

I look forward to hosting my Danish friends in Boston to show them our work with telemedicine/telehealth and patient/family engagement.   I return to Boston tomorrow and then head to China on Saturday for a series of keynotes about innovation, emergency response, and healthcare leadership.   From China I travel to New Zealand to meet with healthcare leaders in Auckland, Christchurch, and Wellington.

Although I limit my international travel to just my “vacation time”, I relish the bidirectional exchange of ideas as we share our experiences, good and bad, with each other with the hope of making a difference in health.

Unity Farm Journal - First Week of October 2016

What a year at Unity Farm: a plague of winter moth, a spring gypsy caterpillar infestation, deep drought, and maybe Hurricane Matthew, which is heading up the coast, might affect our foliage color and branch-falling.    Life on a farm is never boring.

Every October we press cider using the apples that were most successful that season.  This year our mixture is 40% McIntosh, 40% Cortland, and 20% Macoun.    Last weekend we hand pressed 250 pounds and created a cider with a ph of 3.3 and a specific gravity of 1.054 which will yield a finished alcohol by volume of 6-7%.   Although the drought created great stress in the apples, they are very flavorful and we extracted 2.5 gallons of fresh cider per bushel (42 pounds) we pressed.

After two weeks of fermentation, we’ll rack the cider off the yeast, and age over the Winter, bottling and carbonating in the Spring.

As Halloween approaches we always plant garlic and this year, we’ve created a 16’ x 16’ main garlic bed and three 4’ x 8’ satellite garlic beds.   The garlic will grow strong enough before the snow falls and then will become dormant over the winter, exploding with fresh growth in the Spring in time for a July harvest.

We’re starting to experience nights in the 40’s so we moved the pigs from the Summer Cottage to the Winter Pig Palace.   They now spend their afternoons with their bellies facing south to absorb the warm of the sun.    By nightfall they burrow in their hay under blankets and snuggle with each other to keep warm.

As the temperature drops, the last of the black swallowtail caterpillars is finishing its fall meals on dill, anise, and rue plants.   They’ll soon form a chrysalis and overwinter.    Our cornflowers will be filled with young swallowtails in the Spring

One of the most popular items we’ve sold recently at the farmstand are our “hyper-local” honeys.    We have nearly 100 hives spread in town around Sherborn.   The Wellesley honey has been particularly popular.  

Our work on the Unity Farm Sanctuary continues and we’ve signed the purchase and sale agreement, removing all contingencies.    This December, the real work begins as we start to create the educational center and enhanced animal rescue at Unity Farm.

One surprise this week.   Kathy went out the front door to collect eggs and what did she find - three around moms and a dozen new guineas.    Try as we might we have no idea where they nested.   As is typical our 60 guineas want to become 500 guineas every year by building secret nests in the forest.   The babies are warm and feed in the brooder and in 8 weeks, we’ll likely move them to a farm in Maine.

This weekend will be filled with more apple pressing and fermentation duties.  Next week will be a day in Denmark lecturing, then off to China for a week of policy and technology work before heading to New Zealand for an invited lecture.     Kathy and I  agreed that next Fall we’ll put a ban on all travel!