Building Unity Farm Sanctuary - Fourth Week of January 2017

The Board of Directors of Unity Farm Sanctuary held its first meeting at the Unity Meeting House the 1830’s building on the sanctuary property.    The “board room” is the original dining room, made from American Chestnut, which no longer grows in New England due to the chestnut blight of the early 1900’s.   Since the floor is nearly 200 years old, not a single board is square and a marble rolls spontaneously across the floor.

The Board agenda including a walking tour of the entire sanctuary property and a review of all existing survey maps, such as the one below which identifies structures, wetlands, and  topography.

We reviewed several important documents
1.  the IRS Form 1023/supplement requesting charitable status for Unity Farm Sanctuary
2.  an omnibus insurance package including structures, umbrella liability, animal coverage, employee coverage, and even cyber-liability coverage (since we may keep donor data)
3.  a financial sustainability model
4.  a review of infrastructure improvements done to date
5.  a project plan for 2017

The board approved the IRS Form and insurance package.   Yesterday the IRS submission was completed and the journey to non-profit charity began.   The insurance becomes effective this week.

The board also heard about the pending sanctuary animal placement requests.   We explained that poultry, alpaca/llama, and goats are relatively scalable - we can take on additional animals without huge effort.

Horses and pigs are hard.   Horses require a significant degree of daily care and pigs need complex socialization to create a tight knit peaceful community.    We will be adding one additional Welsh pony and one additional pig in February.  Other horse/pig additions will await the construction of new animal care areas shown in the map above.   The existing creatures are happy and healthy.   Here's a few pictures from this week.

Furnishing the sanctuary buildings has been a labor of love.   Kathy has used Facebook and other social media resources to identify people in the community who are moving or downsizing.  We then visited them to explore their attics, basements, and garages.   We’ve purchased items from the 1800’s that could have been in the Unity Meeting House when it was first built.  We’ve kept costs low so that there is no fear of loss/destruction of these furnishings, since the building will be a public space.   The dining room picture above illustrates the kind of pieces the public will use when using the property for events, educational activities, and volunteer opportunities.   We’ve really worked hard to think about high traffic uses, children, and plenty of farm messiness.   The only objects we’re adding to the sanctuary operation are low maintenance, low risk, low worry.

We’re making rapid progress on infrastructure, operations, legal, financial, and governance matters.   Every week brings new possibilities, challenges, and adventure.

What is Care Management?

I recently joined the advisory board of Arcadia Healthcare Solutions, a leading provider of analytics, decision support, and workflow enhancement services.   At my first advisory board meeting there was a rich debate about the marketplace for care management and population health tools.   I’ve spent years studying such solutions at HIMSS and found most of the products are “compiled in Powerpoint”, which is a very agile programming language, since it’s so easy to change…

At BIDMC, we think of care management as two things
*identifying a cohort of patients based on analysis of financial and clinical data
*creating and tracking an action plan for that cohort

We built those core components into our self developed EHR some years ago.   The tools are in very active use to reduce readmissions and improve quality using disease specific protocols.

Other care management services are very important, but we are happy to delegate development of such tools to third party cloud and mobile providers.  Such items include customer relationship management applications supporting case managers, patient facing health coaching, secure patient/family/caregiver groupware, self management resources, and chat/tele-visits.

In my experience, the hardest aspect of care management is unifying financial and clinical data from multiple heterogenous sources, linking the right patient records together, and curating the data to improve data quality.   Once such a foundation is available, then tools for analytics and data visualization can be added on top.  

Most clinicians know they need care management and population health tools, but they are not sure what they need, what questions to ask, and what techniques should be used to turn the data into wisdom, such as risk adjustment.

The Trump administration has signaled its desire to reform Medicare.   Tom Price, nominee for HHS Secretary, has noted that the EHRs are burdensome and quality measures are often misaligned with practice workflows.  Medicaid is likely to be more tightly coupled with local care delivery strategies at the state level.

Despite all these changes, the notion of paying for quality and outcomes instead of quantity will move forward.   The only way to succeed in a value-based purchasing world is to embrace care management techniques that can keep patients healthy in their homes, reducing total medical expense, improving wellness, and enhancing patient satisfaction.  

My advice to Arcadia and to the industry
1.  “it’s the data”,  not a killer mobile app that needs to be the top 2017 priority.   Once the longitudinal community-wide clinical and financial data is collected and cleansed, the rest will follow.    Arcadia has unique expertise in data science, as demonstrated by its high KLAS ratings.
2.  Don’t introduce too many different disparate innovations into clinician workflows simultaneously.  
3.  Spread the care management activity across teams of staff, each practicing at the top of their license - doctors, nurses, case managers, pharmacists, and family caregivers.   Minimize data entry burden.
4.  Partner with other companies and organizations which offer complementary mobile application services
5.  Become a value-added contributor to the EHR ecosystem, not a competitor to EHR vendors.   Although EHR vendors will offer basic population health within their products, no single EHR vendor can combine data across all the sites of care visited by a patient, so third party care management tools will always be important.

I hope this provides a logical roadmap for the care management work ahead and enables you to validate that the organizations promising care management products and services can really deliver them.

Building Unity Farm Sanctuary - Third Week of January 2017

This weekend we’ll run our first Sanctuary board meeting, providing our 7 member board with an overview of

Animals and activities
Financial
Legal
Infrastructure
Projects

Our strategic goals in 2017 are

Develop internship program
Develop educational programs
Develop additional funding possibilities
Develop standard intake process
Develop trail plan in collaboration with the Sherborn Rural Land Trust

Here’s a brief update about what we’ll tell them

In February we’ll take on another horse (Millie, a 20 year old Welsh Pony) and another pig (Penny, the 1 year old Yorkshire).    We’re making modifications to the existing layout to accommodate them.   Likely Millie will run with Sweetie, leaving Amber and Pippin together since they have bonded.   We’re enhancing the outdoor run ins and modifying the barn traffic flow so that 4 animals can easily come and go through the main barn entrance.   We’ve taken on two Bielefelder roosters and they are now integrated into the rest of the flock.    We’ve received requests to take on a few more horses and pigs, which we do not have the space to add over winter.   In the Spring we’ll finish another acre of paddocks/run ins, and hopefully we’ll have a standard intake process by then so the board can help decide which animals we take on permanently and which we help in the short term.

The initial sanctuary budgets are ready for board review and our plan for long term sustainability will be presented.

The 501c(3) IRS filing for the sanctuary has been done.

Last week we refinished all the wood floors and removed about a mile of unused legacy wiring that had powered a 1990’s in building Hi-Fi and video distribution system.   It seems that every property we take on has a endless phone wiring from the 1980’s, cable TV from the 1990’s and sound systems from the early 2000’s.    Now that it has all been pulled we have an electronic greenfield in the Sanctuary, enabling us to add educational technologies as needed.    We continue to improve the barns, fences, paddocks, and run ins with additional hardware and equipment to make daily animal care easier.

This week the dead trees threatening paddocks and buildings come down and we’ll grind them up to cover the paths we’re creating through the property.

It’s exciting to see it all take shape.   Every night we’re at the Sanctuary doing projects.   Every weekend we’re there when we’re not doing direct animal care.   Once the floors are done, the patching and painting of interior walls begins.   In the spring we’ll move to the outside, replacing roof shingles and repairing rot/woodpecker damage.    The big project will be redoing the barn roof, which is sagging.

February is generally the snowiest month in New England, so our project work will get harder.   The Terex PT 30 front loader will work overtime keeping the paddocks, roads, and trails clean.  

So far, so good.  No major surprises in the building of the Sanctuary and the adoption of animals while we’re building.

Dispatch from Scotland

I was in Scotland over the weekend, helping a multi-disciplinary group of academic and government leaders with strategic IT planning.

Scotland, like New Zealand, is a remarkable learning laboratory.  With a population of 5.5 million, a supportive government, and talented informatics professionals, it’s the perfect storm for innovation.

Scotland is driven by 3 urgencies - an aging population, increasing budget pressure, and an imperative to maintain high quality.  All stakeholders in Scotland agree that IT is an enabler to maximize value.

Scotland has a number of infrastructure components currently missing in the US.  It has a lifetime national healthcare identifier.   It has a national image repository.  It has a national emergency medical record.  It has a single team for nationwide healthcare analytics.    It has a single set of privacy laws.   In my recent advice to the Trump administration, I recommended similar foundational work for the US.

In September, the Prime Minister of the UK, Theresa May, released the Wachter Review, a set of recommendations for NHS England that a small team of US and UK experts produced collaboratively.

A few of us are likely to help Scotland with a similar report.

I served the Bush administration for 4 years and the Obama administration for 6 years.   Over the next 4 years, I’m likely to serve administrations in New Zealand, Canada, Scotland, China, and Nordic countries.   There is remarkable power in 5 million person pilots to show the world what is possible when technology, policy, and bottom up stakeholder demand align.

There will be many lessons learned from international collaborators.   I view my role as helping governments avoid the pitfalls I’ve witnessed over my career and engaging appropriate experts to facilitate change.

Scotland and New Zealand are my favored learning laboratories.   Maybe we can create a friendly competition between the two.   A World Cup for healthcare IT awaits.

Building Unity Farm Sanctuary - Second Week of January 2017

After the subzero temperatures and snow of last week, we’re now having spring-like weather  with temps in the 40’s.

The blankets have come off most of the horses (Pippin is still thin and needs a blanket).  Here’s what they look like enjoying the sunshine.

The chickens are also basking in the sun as are the guineas.

The ducks seem impervious to weather and no amount of rain, sleet, ice, snow  or sun seems to bother them.

Of course the Great Pyrenees livestock guardian dogs prefer the snow since their cold weather coats are like down jackets.   Winter is their favorite time of year and they love running through deep snow banks together while snacking on ice along the way.

The wild turkeys are actively looking for food now that they can dig for worms and grubs in the thawing soil.

On the Sanctuary side we’re still awaiting the perfect conditions for tree work - deep snow and mud are both bad.   We need a few dry, cold, snow free days to begin clearing the areas for new paddocks.

The warm weather does mean that do a bit more outdoor repair work on the sanctuary building, replacing rotting wood, clearing gutters, and enhancing the animal housing areas.

We have received so many requests for taking on new animals that we’re brainstorming about the ideal final configuration of run ins, out buildings, and stalls, while also thinking about how to get from the current state to the future state.  In the short term, we’ll likely revise some of the areas we’ve already developed to accommodate larger numbers and a greater diversity of creatures.   Pigs are especially challenging to take on because they require so much socialization to form a stable peaceful community.   If you just put pigs together in a single pen, they will actively hurt each other.

I applaud Jon Stewart’s approach to rescue and public education

His application notes “An estimated 20 farmhands will work on the property, tending to the four to six cows, two to four pigs, six to 10 sheep, six to 10 goats, two to four horses and up to 50 chickens that would live there — all rescued farm animals.”

Today at Unity Farm and Unity Farm Sanctuary we have 13 alpaca, 1 llama, 3 pigs (and a 4th coming soon), 3 goats, 3 horses (and a 4th coming soon), 50 chickens, 50 guinea fowl, 8 ducks, 7 geese, 2 great pyrenees and a million bees.    Since everything is done by Kathy and me with help from one farmhand and one part time intern, clearly we need to work on growing our farmhand population!

We’ll continue our efforts this weekend to strategize about the animals we can take on directly and those we’ll help place elsewhere.   Party of running a sanctuary is being a facilitator, connecting needy animals with resources of all types.   We want to ensure the animals have the right caring home and that means that we have to recognize our own time and financial limitations, ensuring every animal we take on has a forever home with appropriate attention, medical care, and companionship.

My Advice to the Trump Administration

 As I've listened to the confirmation hearings for cabinet nominees, I’ve realized that no one with healthcare IT expertise has yet been identified by the transition team.   I continue to ask all my colleagues about any contact they’ve had with anyone advising the new administration - so far, no one has been asked anything by anyone related to healthcare IT.

At this early time in the administration, it’s important to offer advice as to the priorities ahead for the next few years.    What would I recommend to the new administration?  Here’s my five point plan:

1.  Focus on enabling infrastructure - instead of asking for “pledges” to share more data (the pledge idea should never be used again for anything), create the enabling components that will actually make data sharing easier.  21st Century Cures asks the GAO to research the costs and benefits of a national healthcare identifier.  Let’s create a national healthcare identifier and be done with it.   It’s the simplest and most reliable way to coordinate care across multiple providers and heterogenous EHRs.    Let’s create a national directory of provider electronic addresses that any application can query to make data exchange simpler.   Let’s create a unified baseline privacy policy and universal consent for data sharing across all 50 US states.    As I’ve said many times - you cannot tell the clinicians to drive unless you build roads first.    Suggesting that cars cannot drive because of “transportation blocking” when roads don’t exist is just an excuse for a lack of infrastructure.     Also, the Federal Government needs to practice what it preaches – if DoD and VA don’t share with each other or if all Federal agencies don’t abide by industry-adopted standards and business practices, then the private sector cannot be criticized.

2.  Reduce clinician burden and prescriptive regulations while moving to an outcomes focus.  Demanding that my opthalmologist report smoking cessation and vital sign data is not helpful.    Opthalmologists should be graded based on the visual acuity, field of vision and intraocular pressure of their patients.    The outcome we want is healthy people.  How you achieve it with technology should be up to each hospital and professional.  It’s fine to require some reporting of appropriate quality measures and cost data, but don’t try to dictate the workflow of each provider.

3.  Strong leadership of ONC with deep domain expertise is really important to avoid regulatory zeal.   I describe the later stages of Meaningful Use as “lead a physician to water and beat him/her until he/she drinks”.    There are only 3 ways to influence a clinician - pay them more, improve their quality of practice life, or help them avoid public embarrasment (malpractice assertions, poor quality scores, high cost compared to their peers etc).   If the right tools are created that help with those three items while achieving policy goals, they will be adopted.  You cannot regulate a solution to every societal problem, but you can align incentives so that people act appropriately.   CMS and ONC need to continue to coordinate their work closely.

4.  Focus on cybersecurity and risk mitigation while fostering trust for data exchange.  The new threats to information security and integrity are state sponsored cyberterrorism, hackivism and organized crime.  Every CIO I know loses sleep over these threats.  Let’s work together to identify emerging threats, implement best practices for mitigating risks and investigate promising new technologies like blockchain.

5.  Reward innovation instead of co-opting it.   Every major EHR vendor laments the burden caused by regulatory compliance and certification.   Customer needs and market competition should drive product advancement, not legislation or regulation.  50% of clinicians want to leave the practice of medicine because of the administrative burden.  We’ve achieved exactly what we have required by regulation - turning clinicians into expensive data entry clerks.   Now that high levels of technology adoption have been achieved, companies should sell their products based on usability and efficiency, not certification.

I do not see these five recommendations as abandoning the gains of the past.   I see them as refining the path forward based on what we’ve learned.  The last eight years have achieved remarkable gains and I do not believe we need to lament the gaps remaining, we just need to focus on the right work.

Building Unity Farm Sanctuary - First Week of January 2017

As  temperatures fall and the snow accumulates, work on the Sanctuary gets harder.   It’s -1 degrees F (without wind chill) today and that makes bare handed fine motor movements difficult.  In the early weeks of building the sanctuary, we’re focused on infrastructure -  fencing, heating, plumbing, electrical, and building maintenance.

For the fences, we’ve replaced rotten fence posts and cross pieces.   We’ve replaced the electric fence, rewired the electrical supply to paddocks, and added additional gate hardware to keep the horses and goats inside the fences.   Napoleon, our pygmy goat, figured out a way to break out.   We had an “escaped goat” (Napoleon is to blame).    We watched him as he figured out a way to burrow under the fence!  Who knew goats were so skilled.   We’ve added additional support panels to the place he breached, so the goats are now well contained.

We’ve modified the horse run in to enclose it more fully, keeping the horses warm and out of the wind.

We’ve maintained the yard siphons (underground water supplies) and placed heated buckets in all animal areas so that unfrozen fresh water is also available.

All the light bulbs on the sanctuary property (inside and out) are now LED and the outdoor motion detectors now use high lumens LEDs to keep all animal areas lit when there is movement - predators running by or humans refilling hay in the dark.

We’ve replaced locks so that the entire property has one set of master keys, upgraded door hardware, and lubricated all door and window hardware so that everything works smoothly.

We now have 3 horses and 3 goats housed at the sanctuary and we’ve mastered the daily routines to keep them fed, warm and exercised.    A fourth horse arrives in February (Mille, a 20 year old Welsh Pony mare)

Here’s what the horses look like wearing their blankets and exercising on a cold afternoon.

Our next step with the sanctuary is refinish every floor surface including 1830’s Southern Pine and American Chestnut.    Once the floors are done and cured, we can begin moving in the furniture and equipment that will make the sanctuary a place for public events - tables/chairs, audio visual equipment, and food service equipment.  

We’re making rapid progress and by next month, we’ll be ready to host our first public educational event!

Our 2017 Priorities

In early 2016, I wrote about the 5 pillars of the BIDMC 2016 work plan - social networking, mobile, analytics, cloud, and keeping data private (SMACK)

As we begin 2017, what should be the focus of our work over the next year?

1. Embrace Social Networking concepts in our workflow, including the EHR

Regardless of the policies, repeals, and delays of the Trump administration, we’ll still need to optimize usability and support the four goals of value-based purchasing - quality measurement, total medical expense management, practice process improvement and technology adoption.   BIDMC has already created a prototype of groupware documentation and we should complete our next generation inpatient documentation solution by mid 2017.    Part of that work incorporates open source secure texting as part of the medical record.   We’re also piloting Google’s G-suite so that our stakeholders can store/share, collaborate, and communicate on any device from anywhere using only a browser.  Our vision is to eventually eliminate the need for a managed desktop.    Google G-suite, Amazon AppStream, Office 365 are all options.

2. Make mobile the preferred form factor for interacting with applications

Mobile is not just a shift in form factor, it’s a shift in user experience that can take into account the location of the user and enable different types of user interaction including voice, touch, and gestures.   Mobile is not just a front end client, it also includes a series of back end services such as APIs, BOTS and machine learning.  What do I mean?   A mobile app that uploads a clinical photograph needs an image exchange API with the EHR.   An app that a patient might use to schedule an appointment online might include a BOT to engage in a dialog about time of day preferences and the severity of illness.  We recently installed a bedside medication dispensing unit that tracks patient reported pain scores and patient self-administration of pain meds.   We’ll be able to use that data to better understand how to keep patients comfortable with less narcotic medication.   Tools we are investigating include Amazon Echo/Alexa, image recognition, text to voice, internet of things integration and artificial intelligence.

3.  Enhance Analytics

If you ask 100 doctors to describe population health and care management automation, you’ll get 150 answers.   Our view is that two kinds of technologies are needed - cohort identification and task list management.     Cohort identification should work with structured and unstructured data, enabling patients to be enrolled in a specific disease/care management program using arbitrarily complex boolean expressions i.e. find all patients who have been described in free text notes as “sad” and examine their medication list for classes of therapeutics with depressive side effects.

Once they are identified as part of cohort, a care plan of arbitrary complexity with tracking of tasks to do/tasks undone should enable a care team to take responsibility and ensure all loops are closed.

We’ve built such a system for several conditions already and we’ll make the tools even more flexible over the next year.

4.  Migrate to the Cloud

BIDMC’s cloud application services will be open for business in 2017.  We’re taking a
careful approach but we’re very much on a trajectory to maximize sensible usage of cloud services.

In past years, cloud services were limited to low risk decision support databases and online educational materials purchased via subscription from content vendors.   That’s analogous to buying the New York Times online from the cloud.   Today we have contracts in place with Amazon Web Services for application hosting/storage/analytics, Google for G-Suite, and Dell/NTTData for community hospital EHR hosting.  Additionally our community ambulatory practices use AthenaHealth’s EHR/practice management from their cloud

We believe we can achieve high reliability, robust geographically distributed disaster recovery, security best practices, lower cost, and enhanced scalability with these services.

Our experience suggests that IT FTEs are unlikely to be increased.   The only way to enhance innovation and customer service is to move the work that can be moved to the cloud, freeing up time of existing IT FTEs for new work.

One of our challenges has been ensuring network latencies over the internet are low.    We created a 10 Gigabit dedicated network connection using AWS's Direct Connect service connection from our network core to Amazon with a latency of 11 ms maximum.  You cannot tell the difference between locally hosted and cloud hosted.

Most mainstream cloud hosting companies will now sign a business associate agreement (BAA), following industry best practices (NIST 800-66, COBIT, ITIL) for protecting patient privacy.   All over our vendors have provided us with  third party audits demonstrating adherence to some reasonable security and privacy framework.

Although many companies are willing to implement privacy controls and sign a BAA, almost no company is willing to indemnify customers for privacy breaches.   We have purchased a third party cyber liability policy.  

5. Keep information private

Security will continue to be a major focus.   In 2017, we’ll roll out  two factor authentication which will serve as a foundation for e-prescribing of controlled substances as well as mitigating the risks of password theft.

We’ll continue our Blockchain experiments as a way to keep data safe and ensure data integrity across multiple organizations as we coordinate care across the continuum of the patient experience.


Those are the 5 pillars for 2017 and the next technologies we’ll explore to support them.

Just as in previous years, I can say that I’m excited by the Healthcare IT adventures ahead.