Building Unity Farm Sanctuary - Third Week of February 2017

As the weather begins to warm, work on the sanctuary gets easier.    Snow and ice are melting.   We’ve taken the blankets off the horses and left the doors/windows on barns open overnight.   Turkeys and deer are looking for food on the newly visible ground, causing the dogs to bark all day and night.

This week, Millie, a 23 year old Welsh pony arrived at the sanctuary.   She immediately bonded with Pippin, our 30 year old Welsh pony.   Amber and Sweetie hang out on one side of the large paddock, Millie and Pippin on the other.   Everyone is getting along well.

Millie’s arrival was a bit rocky.   Her owner drove Millie from Central Massachusetts to Unity Sanctuary and one mile from us, the diesel truck pulling the horse trailer just stopped.   Nearby police arrived to direct traffic and Millie was safely removed from the trailer and walked down a side street.    One of our neighbors, the Dowse family, saw the problem and immediately came to the rescue, hauling the trailer out of harm’s way and to the sanctuary.  The truck was towed back to Central Massachusetts and a mechanic found  fuel line failure.

Now that the floors and walls of the sanctuary have been refinished, we’re in full swing with classes and meetings.  Here’s a glimpse of our efforts to restore colonial colors to every room.

Friday yoga meets in the third floor loft of Unity Hall.  Sunday drop in meditation meets in the great room on the first floor of Unity Hall.   Retreats are scheduled for March.   The commercial-grade heating, plumbing and electrical systems are ready for them.

My nights and weekends (when not at HIMSS) have been spent on carpentry, window repair, and furniture refinishing.  At this point we’re completed our search for 1800’s furniture in local basements, attics and even the town dump.   Here’s what it all looks like.

This weekend, Penny the Yorkshire pig arrives we’ll begin the process of socializing her into the herd.   She’ll need extra reassurance since this will be the first time she’s left her mom/dad and the comforts of her home.   We’ll keep her safe for a year, hoping that she’ll return to her “parents” once they’ve found a new place which a dedicated pig habitat.   We'll work on trails, paddock planning, and recovery from the past 4 months of below freezing weather.

Dispatch from HIMSS 2017

As I wrote last week, I expected 2017 HIMSS to be filled with Wearables, Big Data, Social Networking concepts from other industries, Telemedicine, and Artificial Intelligence.

I was not disappointed.   42,000 of my closest friends each walked an average of 5 miles per day through the Orlando Convention Center.  One journalist told me “It’s overwhelming.  You do your best to look professional and wear comfy shoes!”

After 50 meetings, and 12 meals in 3 days, here’s my impression of the experience

1.  Wearables, while still relevant have gone from the peak of the hype curve to the trough of disillusionment.   Google Glass, smartwatches, and innovative fitness trackers have not quite achieved their promised potential in healthcare and no one is quite sure how to integrate their data into the workflow.    That being said, Internet of Things is bigger than in previous years, with home scales, glucometers, and blood pressure cuffs becoming more connected than ever before.  Middleware like Apple Healthkit has significantly reduced the interfacing burden.

2.  Big Data has morphed into Care Management and Population Health.   We’re at a point in history when healthcare data has become digital but few are sure how to turn that data into wisdom.   Decision support services that analyze problem lists, medications and genomic data, producing customized care plans are emerging.  The challenge is connecting them to the EHR workflow.   The Argonaut work group met for a few hours to decide on the next interoperability capabilities for FHIR and chose scheduling workflow and clinical decision support integration.  This means that any third party developer will be able to integrate their analytic functionality into EHR workflow, generating alerts and reminders and scheduling services (appointments, surgery, infusions/therapy, referrals, and even post acute care) with limited effort and cost.      To me the most important theme at HIMSS 2017 was that FHIR/APIs, cloud hosted services, and EHRs will come together in 2018 similar to the way the iPhone spawned the app store.   Assume every EHR company will have a curated app store and sandbox for developer education/pilot testing within a year.

3.  Value-based purchasing has generated an interest in customer relationship management - the patient as partner and consumer.  As reimbursement moves from fee for service to quality/outcomes driven risk contracts, incentives are aligned to provide wellness services, “care traffic control”, and loop closure.    EHRs are not optimized for these functions, so third parties are offering cloud-hosted customer relationship management for healthcare.

4.  Telemedicine and Telehealth continues to grow as efforts to reduce total medical expense move care from downtown academic tertiary referral facilities to lower cost, more convenient alternatives in the home.  Telemedicine means many things and ranges from on demand virtual urgent care visits to store/forward second opinions to expert staff augmentation from a distance.   Products are evolving that enable telemedicine record keeping, billing, and mobile device secure communications.

5.  Artificial Intelligence/Machine learning is the new “plastics”   .   There is no question that AI is the peak of the hype curve this year.  We need to be measured about our expectations for this technology.   Computers do not “think”,  they use pattern matching to focus the attention of humans, separating signal from noise.    There are great use cases for machine learning - automating sorting of paper medical records for scanning by predicting metadata, scrubbing personal identifiers from unstructured data, and suggesting reasonable ICD10 codes for episodes of care.    It’s not likely that an AI system is going to read the Merck Manual tonight and replace your doctor tomorrow.

Although my voice is nearly gone, I’m leaving HIMSS with optimism for the industry.   EHR vendors will increasingly share data with each other and with third party developers.  Usability will improve as new applications and analytics reduce clinician burden.   Patients will increasingly be equal members of the care team providing objective and subjective data from devices and mobile apps in their home.  

As I’ve said before, I believe the next phase of history belongs to the private sector, so for all of the developers, customers, and experts at HIMSS, it’s all up to you.

Preparing for HIMSS 2017

Next week, 50000 of our closest friends will gather together in Orlando to learn about the latest trends in the healthcare IT industry.

What can we expect?

I’ll be giving a few keynote addresses, trying to predict what the Trump administration will bring, identify those technologies that will move from hype to reality, and highlighting which products are only “compiled” in Powerpoint - a powerful development language that is really easy to modify!

Here are a few themes

1.  The Trump administration is likely to reduce regulatory burden but is unlikely to radically change the course of value-based purchasing.    This means that interoperability, analytics, and workflow products that help improve outcomes while reducing costs will still be important.   Fee for service medicine will diminish over time, so focusing on quality healthcare will be more important than increasing the quantity of tests, procedures, and visits.   Novel products and services will be needed since the existing EHR is not designed for optimizing wellness, it’s designed for documenting/billing encounters.

2.  Precision Medicine that tailors care plans and therapeutics based on the unique characteristics of each individual will continue to be important.    Although there is much discussion of genomic medicine but even simple innovations can make an impact.  For example, my wife needs to take 3.75mg of Methimazole every day but the medication is packaged as a 5mg tablet she needs to cut into quarters.  Why not offer a 3D printer that simply “prints” the tablets you need each day?

3.  Care Management solutions that treat the patient as customer will continue to be important.   Sharing care plans, monitoring progress on those plans, and engaging patients/families as a shared decision maker will require innovation.

4.  Artificial intelligence/machine learning will be at the peak of the hype curve this year.   IBM Watson will not replace clinicians, but the notion of using software for pattern matching does work well.

5.  Internet of things, patient generated healthcare data, and telemedicine/telehealth will be increasingly important tools as we strive to reduce total medical expense, address the needs of an aging society, and enable our clinicians to practice at the top of their license.  

I’ll be running from venue to venue Sunday-Wednesday.   See you there.

Building Unity Sanctuary - Second Week of February 2017

I have been traveling in Japan and New Zealand this week so Kathy had to manage the sanctuary and farm.

The major challenge has been the snow, ice, and cold.   While I’ve been away, 18 inches of snow have fallen, making sanctuary operations more challenging than usual.

Pippin, our 30 year old Welsh pony is recovering nicely after his tooth surgery.   He stopped eating and lost weight rapidly because it hurt so much to chew.   The vet sedated him and removed the offending tooth by breaking it into 3 pieces.  Antibiotics cleared an underlying gum infection and his appetite returned.   We’ve enhanced his diet with timothy hay pellets, a mixture of high fiber grains for senior horses, and grass hay.  It’s great to see him healthy and happy again.

The other horses, Amber the Arabian mare, and Sweetie, the Welsh pony, continue to thrive and the herd gets along well.    We’ve moved them into the barn during the storms to keep them warm and and dry.

We learned this week that goats do not like to eat off the ground.   We’ve been creating piles of timothy hay for them and although they’ve eaten them, they left a lot behind.   Kathy ordered a wall mounted goat feeder for me to install when I return.

In my absence Kathy has organized classes at the Sanctuary and juggled interior painting/repair work around the classes.   She’s also designed a second run in for the goat paddock so that we can house rescue donkeys in the same space as the goats.   Donkeys can serve as a livestock guardian animals, keeping the goats safe from coyotes, bobcats, and other predators.   There is a wonderful donkey rescue organization in New England that we’ll be working with.

I’ve begun conversations with other non-profits in our local community about how best to collaborate.   We can share our sanctuary space for educational events, connect our trails to other community walking trails, offer our support to other local causes.  Since our goal is to use the Unity Sanctuary as a public gathering space for the benefit and education of the community, it’s important that we identify all the possibilities and present them to the Sanctuary board for discussion.

Next week, a Welsh pony, Millie, arrives as well as Penny the yorkshire pig.   Our paddocks and barns are ready to receive them.    Our daily routines of alpaca care, pig care, horse care, poultry care, and dog care are now optimized, so we are efficient at meeting everyone’s needs.

I return to Boston on Friday night and will spend the weekend doing all the maintenance, repair, and building tasks I missed during the week.   HIMSS (a major national IT conference) begins next weekend, so February is a tricky month to balance job, farm, sanctuary, live and travel.   So far, so good.

Dispatch from Japan and New Zealand

This week I’ve taken vacation time to help my colleagues in Japan and New Zealand with national IT planning.    As I often say, the healthcare IT challenges are the same all over the world, but the cultural context is different.

In Japan, I spent 2 days in Tokyo and 1 day in Kyoto, lecturing, meeting, and listening to stakeholders.   There is a great desire to share data for care coordination and clinical trials/clinical research.   Telemedicine/telehealth is increasingly important in an aging Japanese society that has increasing healthcare needs but a limited number of caregivers and few opportunities to increase healthcare budgets.  Here are a few of the current issues we discussed:

1.  Some early data exchange pilots in Japan have used a healthcare specific XML form called Medical Markup Language (MML).  Others have used IHE standards such as XDS.b . There is not universal adoption of a specific content standard among the majority of Japanese EHRs, many of which are custom created for each hospital.    I recommended that Japan adopt CCDA as a summary content standard and FHIR as a query/response standard.

2.  There is limited adoption of controlled vocabularies.   SNOMED-CT, LOINC, and ICD-10 are used in pockets, but are not mandated by national or local regulations.     There is some early work being done on OpenEHR and the use of schemas/archtetypes to represent data in a semantically interoperable way.    I recommended the universal adoption of a single controlled vocabulary for each clinical area - SNOMED-CT for problems, LOINC for Labs and ICD-10 for diagnoses.

3.  There is no standard means to send/route data across the country.   Japanese privacy laws are not “internet friendly” and require the use of VPNs, leased lines, dedicated fiber etc.     I suggested that https over REST is good enough.

4.  There are not significant incentives to adopt healthcare information technology.   Although I did not encourage a Meaningful Use program for Japan, I did highlight the notion in HITECH of creating carrots and sticks for achieving specific policy goals.

5.  Prime Minister Abe wants more entrepreneurial Japanese, but that is challenging  in a country where the failure of a startup is considered a reputational risk.   Building a startup culture requires the creation of a "safe zone" where risk and rapid failure are tolerated.

In New Zealand, I met with government ministers, academia, industry, providers, and patients to describe my international experiences with healthcare IT innovation and how lessons learned might apply to New Zealand efforts.  There is a remarkable alignment of government sponsorship, technology expertise, and an urgency to change in New Zealand.   The desire to share data for quality measurement, care management, and enhancing social services extends to the highest levels of government.    With 5 million people, a national healthcare identifier, well organized district health boards, uniform privacy laws, and a robust planning process, New Zealand truly is the perfect storm for healthcare IT innovation.    Here’s my sense of their short term priorities

1.  Complete their current multi-stakeholder engagement process to define priorities for the next 5 years

2.  Determine the range of privacy preferences in New Zealand society then implement the technology and policies needed respect those preferences for multiple uses of data

3.  Based on their high priority business cases, develop appropriate tools to push, pull and view data among stakeholders

4.  Encourage an ecosystem of innovation so that startups can build products which plug into existing enterprise software

5.  Focus on the needs of patients and families by ensuring they collaborate in producing and managing their healthcare data.

Just as I’ve done with the England, Scotland, Canada,  Nordic countries, and China, I wrote briefing/position papers for leaders in Japan and New Zealand before I left.  

I’ve said previously that my goal in life is to make a difference.  If I can be a catalyst around the world to accelerate healthcare IT best practices, mitigate risk, and minimize repeated mistakes, I will have achieved my goals.

Building Unity Farm Sanctuary - First Week of February 2017

Running an animal sanctuary requires constant attention to the care and well being of all the creatures living there.   This week, Pippin, our 30 year old Welsh pony stopped eating hay and required urgent intervention.    He did not appear to be suffering from colic.  He ate treats and sweet grain, which we minimize because of his Cushing’s disease.   We knew he had numerous dental issues but to evaluate the situation he needed to be sedated.   The vet figured out he had a loose tooth that prevented him from chewing grasses.    She removed the tooth, placed him on antibiotic coverage and gave us two nutritional supplements to help him get back on his regular diet.    As an older, thin pony, he lacks reserve so we’re very focused on increasing his caloric intake, maximizing his weight gain over his Cushing’s treatment.   I’ll report back on his progress over the next week.

Community events at the sanctuary have begun with yoga classes and meditation classes meeting in the Unity Meeting House.   All the floors in the building have been freshly refinished and the odor of polyurethane has faded.   Daily fresh air ventilation and a bit of incense has made the building very pleasant.  

Only two rooms in the building had carpeting and we’ve replaced all with pre-finished wood in keeping with the 1830’s look of the original building.    Kathy will hold an art retreat in the newly finished third floor space next weekend

We’ve also continued repainting the entire inside of the building using beiges and blues consistent with the older finishes.   All the remaining wallpaper from the 1980’s and 1990’s will soon be replaced with the vintage paint colors.

We’ve carefully inspected all the exterior wood surfaces and we’re replacing anything rotted/decaying with azek, especially anything at ground level.     The work on the wiring, plumbing, telecom, audio, and security will be done by next week.

Over the past 50 years, workman have left pieces of retired heating ducts, electrical boxes, and lumber in the crawlspace below the house.    Using my toughened mountain climbing clothes, I’ve crawled through every square foot under the house and bagged up all the debris.   Another few hours of work next weekend and the entire crawlspace will be as it was when the house was first built.

Hopefully our efforts in March will focus on the animal housing and paddock areas - we’re hoping for cool, dry weather to make it possible for us to finish clearing fallen logs, rocks, and brush, enabling us to begin the new fencing  which will surround the new rescue areas.

This week, we built a new “toy” for the goats - a 4x4 foot platform, 18 inches high.   They play king of the mountain, climbing on the platform and knocking each other off until only one is left.   Typically Napoleon wins the battles.   He’ll even carry a pine branch onto the platform, so he can enjoy a snack while surveying his domain.

Next week I’ll be in Japan lecturing,  meeting with government/industry/academia, and spending time with old friends.   Kathy will be running the farm and sanctuary operations with the help of our growing team of volunteers, interns and helpers.    I’ll be in constant touch, ensuring all is well.

We Must Think and Act as One Planet

Over the past few days, several journalists have asked me to comment about travel bans, immigration policy changes, and trends in isolationism.

My opinions are my own and do not reflect any official position from my employer or my academic affiliation.

Here are my observations

1.  Information Technology is global.   We hire the best talent regardless of nationality, gender identity, sexual orientation, religion, or race/ethnicity.   Having worked in 75+ countries in my adult life, I can say that innovation crosses all boundaries and cultures.   It’s just as likely that next big breakthrough will come from EMEA as it is from APAC.  I cannot imagine restricting the flow of collaboration among academics and technology professionals from any country.

2.  I was born in 1962.   My grandmother described that for much of her life drinking fountains were separated based on race.  Other relatives have talked to me about the controversy of electing John F. Kennedy, a catholic, as president.   My mother was one of the first female law school graduates from her school.  As a society, we’re moving past issues of classifying people and limiting their roles.  2017 is not  a time to divide the world into “us” and “them”

3.  In my youth, Fedex (overnight shipping) did not exist.   Software could not be downloaded.   Communication was by paper letter.   At this point in history there are no barriers to instant communication and information sharing around the world from every person and culture to every other person and culture.

4.  Many of the skills that have made me successful in life are now completely obsolete.   I could type very accurately and produce flawless sheets of text on my Smith Corona.   I could search the card catalog at public libraries and read literature very fast to find salient facts and quotes.   I could memorize large amounts of information - a kind of human Hadoop.    Today, no one needs such skills.   Google, Amazon, Facebook, Twitter, and Netflix skills are much more valuable.   Automation has completely changed the job market.   Immigrants are not taking away jobs, but the evolution of work itself has led to the “rust belt” and the closing of US factories.    It’s naive to believe that building a wall or restricting the flow of people will bring back the jobs at the “plant” of the 1970s to middle America.

5.   I am a first generation American.  My mother was born in Latvia.   My father’s family is from Prague.   What makes our family, which immigrated in the 1950s any different from a family trying to immigrate in 2017?   An immigrant is an immigrant regardless of the country of origin or time period.   If we blocked Steve Jobs’ family from immigrating out of Syria, Apple would not exist.   Is that what we want?

The bottomline is that we’re a global economy, dependent on each other for resources, ideas, and innovation.    Throughout the world we’re seeing globalism being abandoned in favor of regionalism.    Many believe that by dividing the world into the haves and have nots, we’ll improve the situation from some while diminishing the situation of others.   Some will win and some will lose.   This is very short sighted since we’re only one finite planet with finite resources.   We need to think as one planet, one people, and one species.   Rhetoric, demagoguery and populist rabble rousing may seem appealing in the short term but they do not address the critical problems we face today - climate chance, environmental destruction, and a population that exceeds the carrying capacity of the available resources.

My role in 2017 is to serve the world around us, embracing all people, and openly sharing ideas.   I will not criticize the officials in the current US administration but I will criticize their ideas.     The era of US leadership is fast coming to an end and building walls will only accelerate our demise.   I look forward to a future when we all recognize that our work is the successful future of a unified human species, not a return to a past that can never exist again.