Although this week will be lighter because of the holidays, the work never ends. At the Sanctuary, I'm using our Terex skid steer and its attachments (consensus method from forums suggests the "blade" to create windrows then the snowblower attachment to move the windrows. Light snow - blade only). Although we did not receive more than a few inches of snow, we are getting early bitter cold, so snow will not be melting for the next 10 days. It was a very white Christmas!
Here's my technology Christmas list for 2017
The Sanctuary now uses outdoor Nest cameras so that we can remotely view the animals to better keep them safe.
To enhance reliability, I needed to install a mesh network first to boost the signal.
Now we can see what is happening if the Great Pyrenees bark at night, or if we hear Star the donkey braying.
May your 2018 be happy and healthy.
Tuesday, December 26, 2017
Thursday, November 30, 2017
Another Dispatch from a Broken Healthcare System
I'm working on a series of "Dispatches from a Broken Healthcare System" based on my personal experience as a care navigator. I've already written about a frustrating care management experience
Today's blog is a guest post from Amy Stiner, a healthcare expert and single mom from the Pacific Northwest. She reflects below on what should be a simple task - transferring records between institutions in the age of Meaningful Use.
"My name is Amy Stiner and my healthcare consulting career has taken my 6-year old son, my mother, and me progressively across the country. Over the course of Grant’s sweet little life, he has been a patient at 8 nationally recognized academic health systems. In a sentence, my son has a severe form of ADHD with an extremely severe feeding disorder without a clear etiology. He is progressively starving to death.
We have experienced healthcare delivery in a variety of health systems in cities that are inclusive of Boston, St Louis, Chicago, Honolulu, and Seattle. Even exotic, Eau Claire, Wisconsin. After leaving Boston in 2011, things have gotten messy with medical records and transfers of care.
Based on my experience, the two biggest contributors to the delays in transitions of care across America have been:
1) Medical Record Requesting
2) Transfer of Care Handoff/Provider Referrals/Conversations
By far, the biggest offender is the medical records requesting process. You may be wondering - how is it possible that requesting medical records is creating such massive delays in care? The answer is not straightforward, but rather a sequence of events that delay initial appointment scheduling. This exercise has become a series of hoops to jump through, ultimately obtaining that ‘prized appointment’ with a specialist or sub-specialist. I am a mother and clinician who is constantly pursuing the ‘gastroenterology and feeding clinic appointment merit badge’.
The Mission Should I Choose to Accept It
Every time I attempt to get him established with a new health system, I am more often met with a brick wall of obstruction at the entry point for care rather than a welcome mat. The initial appointment conversations (90% of the time) go something like this:
“Before your son can be scheduled—we need to have a copy of (1) the medical records and (2.) referral/phone call person to person conversation from your former physician.”
Hearing that sentence alone is enough to make my voice raise a whole octave. They know and I know that ‘patient first care’ is never a part of that sentence. I have been in this industry long enough to know why they have made it my problem to chase information because providers can’t seem to obtain it efficiently either. If my child’s condition worsens or if he is running out the prescription formula that he needs the health system doesn’t suffer but my son, my mother, and I do. Delays in patient care hurt the whole family.
A Convoluted Process of…Processes
Once again, I am being given my marching orders by the new patient in-take person. Go find all the records. Go chase your referring physician for a physician to physician phone call. “Don’t call us, we’ll call you when we get around to it after we receive everything and only if we remember to look for them and don’t lose your records first.” Its like a Monty Python sketch. It would be funny if it wasn’t true.
I hang up the phone, fighting back swear words and tears. I know that I don’t have the time during a work day, while in a different time zone, to chase these things. That the evening, when I should be reading a bed-time story to my son or trying to get him to take in a few more life sustaining calories, I will instead be downloading 8 different multi-page medical request forms to my PC. Then I’ll remember that I don’t think I have enough ink in the printer for all the pages. One academic health system (with Nobel Prizes in Economics) has three (3) pages of instructions on how to fill out the two (2) page request form. It then follows those instructions up with all the different postal addresses that the form will need to be copied and mailed too. Yes. Postal mailing the same form in different envelopes to different locations for the same health system. Ironically, we are all not realizing economies of scale in this process.
Each form makes me carefully select all the locations of patient care within the health system, where my son has been seen. Why can’t they just aggregate it based on his account number or something and magically pull it all together? They all make me choose if I want notes, records, images, mental health, reproductive health, and more. I always anxiously look for the “ALL RECORDS TICK BOX”—EVERYTHING!!! I WANT EVERYTHING!!! There isn’t a magical everything box, so I resentfully tick mark each individual little box for everything.
I hurriedly complete this information on 8 different multi-page forms for each health system and the instructions sound like a lecture from a teacher in high-school “If the information provided is incomplete records will not be sent.” I really hate this process and I suddenly realize I don’t have enough postage stamps to mail the ones that need to be mailed. I now make an unplanned trip to the post office. I am angry, and the printer is beeping as I walk out the door to get stamps.
The Options Aren’t Impressive and Not User Friendly
Along with all the above I am asked to select the media by which the health systems will send and receive the information. Disc? Paper? Images? Some simply tell me what the doctor is going to get. That’s it. The doctor doesn’t get a choice—the doctor is going to get paper or a disc and hopefully that provider can just deal with the paper or disc that is being sent. I can’t use the disc, my PC doesn’t have a disc drive. I pray the physician has one.
Receive a paper copy of the information myself? I must pay for it. Lord only knows how many pages there are? Some health systems charge per page. Why aren’t these items in the portals or sent in an electronic format? It is 2017 and surely healthcare technology should be adopted to handle this seemingly simple task?
The Mystery Treasure Hunt Ensues
I have never seen the full records from any of the facilities that have cared for my son and have no idea what is already existing in each one from a prior provider. I assume they are a mess. Each move, I have requested medical records from every single place just to be on the safe side (to get everything). In theory there should multiple copies in the record from each past health system. Based on recent experience, I imagine they haven’t received much because I had to do this whole thing twice, and only after that duplicated process did we receive one single copy from one institution in Chicago. Although we didn’t know initially if anything had really been received.
After my insistence, a kind-hearted network of health system leaders formed a medical record search party. They looked for anything sent from 8 institutions with my son’s name on it. “OH, WAIT! WE FOUND ONE OF THEM!” cried the search party. The HIM department didn’t know what to do with the information—because they had no existing record to put it in. It was set aside until a record was started. (See how that worked?) We are delighted for the recovery and it calls for a celebration. I bought a bottle of wine and my mother was ecstatic on all fronts.
The Result
One year later, my son finally had his appointments after the initial step of the process was begun, the result of delayed records and missed phone calls between physicians with never ending phone tag. The outcome of those appointments now has us planning a return to the East Coast. His weight loss is worse than last August 2016, and his level of care involves more complexity in delivery. The silver lining in all of this, is that I have an amazing son and I am 100% committed to this marathon in a race against time for him and others. There are other parents/care givers who are running the marathon with less time left than we have. What will days, weeks, and months of delayed care have cost all of us because of dangerous medical record request and referral processes we have in place? My little guy and I are eternal optimists. We believe that those of us in healthcare can and will do better. Immediately. "
Today's blog is a guest post from Amy Stiner, a healthcare expert and single mom from the Pacific Northwest. She reflects below on what should be a simple task - transferring records between institutions in the age of Meaningful Use.
"My name is Amy Stiner and my healthcare consulting career has taken my 6-year old son, my mother, and me progressively across the country. Over the course of Grant’s sweet little life, he has been a patient at 8 nationally recognized academic health systems. In a sentence, my son has a severe form of ADHD with an extremely severe feeding disorder without a clear etiology. He is progressively starving to death.
We have experienced healthcare delivery in a variety of health systems in cities that are inclusive of Boston, St Louis, Chicago, Honolulu, and Seattle. Even exotic, Eau Claire, Wisconsin. After leaving Boston in 2011, things have gotten messy with medical records and transfers of care.
Based on my experience, the two biggest contributors to the delays in transitions of care across America have been:
1) Medical Record Requesting
2) Transfer of Care Handoff/Provider Referrals/Conversations
By far, the biggest offender is the medical records requesting process. You may be wondering - how is it possible that requesting medical records is creating such massive delays in care? The answer is not straightforward, but rather a sequence of events that delay initial appointment scheduling. This exercise has become a series of hoops to jump through, ultimately obtaining that ‘prized appointment’ with a specialist or sub-specialist. I am a mother and clinician who is constantly pursuing the ‘gastroenterology and feeding clinic appointment merit badge’.
The Mission Should I Choose to Accept It
Every time I attempt to get him established with a new health system, I am more often met with a brick wall of obstruction at the entry point for care rather than a welcome mat. The initial appointment conversations (90% of the time) go something like this:
“Before your son can be scheduled—we need to have a copy of (1) the medical records and (2.) referral/phone call person to person conversation from your former physician.”
Hearing that sentence alone is enough to make my voice raise a whole octave. They know and I know that ‘patient first care’ is never a part of that sentence. I have been in this industry long enough to know why they have made it my problem to chase information because providers can’t seem to obtain it efficiently either. If my child’s condition worsens or if he is running out the prescription formula that he needs the health system doesn’t suffer but my son, my mother, and I do. Delays in patient care hurt the whole family.
A Convoluted Process of…Processes
Once again, I am being given my marching orders by the new patient in-take person. Go find all the records. Go chase your referring physician for a physician to physician phone call. “Don’t call us, we’ll call you when we get around to it after we receive everything and only if we remember to look for them and don’t lose your records first.” Its like a Monty Python sketch. It would be funny if it wasn’t true.
I hang up the phone, fighting back swear words and tears. I know that I don’t have the time during a work day, while in a different time zone, to chase these things. That the evening, when I should be reading a bed-time story to my son or trying to get him to take in a few more life sustaining calories, I will instead be downloading 8 different multi-page medical request forms to my PC. Then I’ll remember that I don’t think I have enough ink in the printer for all the pages. One academic health system (with Nobel Prizes in Economics) has three (3) pages of instructions on how to fill out the two (2) page request form. It then follows those instructions up with all the different postal addresses that the form will need to be copied and mailed too. Yes. Postal mailing the same form in different envelopes to different locations for the same health system. Ironically, we are all not realizing economies of scale in this process.
Each form makes me carefully select all the locations of patient care within the health system, where my son has been seen. Why can’t they just aggregate it based on his account number or something and magically pull it all together? They all make me choose if I want notes, records, images, mental health, reproductive health, and more. I always anxiously look for the “ALL RECORDS TICK BOX”—EVERYTHING!!! I WANT EVERYTHING!!! There isn’t a magical everything box, so I resentfully tick mark each individual little box for everything.
I hurriedly complete this information on 8 different multi-page forms for each health system and the instructions sound like a lecture from a teacher in high-school “If the information provided is incomplete records will not be sent.” I really hate this process and I suddenly realize I don’t have enough postage stamps to mail the ones that need to be mailed. I now make an unplanned trip to the post office. I am angry, and the printer is beeping as I walk out the door to get stamps.
The Options Aren’t Impressive and Not User Friendly
Along with all the above I am asked to select the media by which the health systems will send and receive the information. Disc? Paper? Images? Some simply tell me what the doctor is going to get. That’s it. The doctor doesn’t get a choice—the doctor is going to get paper or a disc and hopefully that provider can just deal with the paper or disc that is being sent. I can’t use the disc, my PC doesn’t have a disc drive. I pray the physician has one.
Receive a paper copy of the information myself? I must pay for it. Lord only knows how many pages there are? Some health systems charge per page. Why aren’t these items in the portals or sent in an electronic format? It is 2017 and surely healthcare technology should be adopted to handle this seemingly simple task?
The Mystery Treasure Hunt Ensues
I have never seen the full records from any of the facilities that have cared for my son and have no idea what is already existing in each one from a prior provider. I assume they are a mess. Each move, I have requested medical records from every single place just to be on the safe side (to get everything). In theory there should multiple copies in the record from each past health system. Based on recent experience, I imagine they haven’t received much because I had to do this whole thing twice, and only after that duplicated process did we receive one single copy from one institution in Chicago. Although we didn’t know initially if anything had really been received.
After my insistence, a kind-hearted network of health system leaders formed a medical record search party. They looked for anything sent from 8 institutions with my son’s name on it. “OH, WAIT! WE FOUND ONE OF THEM!” cried the search party. The HIM department didn’t know what to do with the information—because they had no existing record to put it in. It was set aside until a record was started. (See how that worked?) We are delighted for the recovery and it calls for a celebration. I bought a bottle of wine and my mother was ecstatic on all fronts.
The Result
One year later, my son finally had his appointments after the initial step of the process was begun, the result of delayed records and missed phone calls between physicians with never ending phone tag. The outcome of those appointments now has us planning a return to the East Coast. His weight loss is worse than last August 2016, and his level of care involves more complexity in delivery. The silver lining in all of this, is that I have an amazing son and I am 100% committed to this marathon in a race against time for him and others. There are other parents/care givers who are running the marathon with less time left than we have. What will days, weeks, and months of delayed care have cost all of us because of dangerous medical record request and referral processes we have in place? My little guy and I are eternal optimists. We believe that those of us in healthcare can and will do better. Immediately. "
Monday, November 20, 2017
Dispatch From South Africa
My blog readers must think I've abandoned them over the past few weeks. I apologize for the whirlwind of October and November. With the BIDMC-Lahey merger planning and the new cloud hosted Meditech go lives of my day job, plus the usual Fall conference commitments, and my new work with the Gates Foundation, blogging has fallen behind.
The Gates Foundation has a bold plan for Africa - unifying the health records of the continent using biometrics, simple phone apps, and a highly resilient low bandwidth cloud that includes data integrity components based on blockchain.
Here's the use case - patients with HIV are medicated and then monitored for viral suppression using Viral Load lab tests drawn 6 months after therapy begins. This process requires accurate patient matching between clinic visits, which might occur at different locations and with different care providers.
In the US, exact matching of demographics works about 60% of the time. Probabilistic models work about 80% of the time. South Africa has a similar experience. The end result is that many lab tests are redundant and wasteful. Measuring outcomes is challenging. Closing the loop for followup may be impossible. Biometrics can improve matching to 99%, improving quality, safety and efficiency.
South Africa has a "90/90/90" national strategy - 90% of HIV positive patients should know they are HIV positive. 90% of those should be on anti-retroviral medication. 90% of those should have documented viral suppression with viral load tests.
I've joined an amazing multi-disciplinary team that includes the Gates Foundation, biometric engineers, app developers, usability experts, cloud database/blockchain innovators, and security professionals.
Over the course of 5 days we met with government, academic, and industry leaders throughout South Africa to plan a 2018 pilot of a nationwide patient matching strategy. We've devised objective metrics for success that include improvements in patient and provider satisfaction as well as reductions in total medical expense.
I've written about the Perfect Storm for Innovation. South Africa has all the ingredients - senior leadership of top government healthcare leaders, a guiding coalition of people to oversee the work, appropriate resources to do the work, and an urgency to innovate. I'm hoping that the work in Africa will demonstrate how a nationwide patient matching strategy can work, serving as a model for the world, including the US which continues to struggle i.e. CHIME cancelled its patient matching challenge
The South African people are amazingly kind and helpful. The National Health Laboratory Service has a best in class repository of lab data for the entire country. With Gates funding as a catalyst, I'm convinced we can make a substantial difference in 2018.
In addition to visiting clinics, labs, data centers, hospitals, and IT departments, I had the opportunity to visit an animal sanctuary near the border of Botswana. It's just like Unity Farm Sanctuary except that instead of pig belly rubs, I gave lion belly rubs. An amazing experience.
The Gates Foundation has a bold plan for Africa - unifying the health records of the continent using biometrics, simple phone apps, and a highly resilient low bandwidth cloud that includes data integrity components based on blockchain.
Here's the use case - patients with HIV are medicated and then monitored for viral suppression using Viral Load lab tests drawn 6 months after therapy begins. This process requires accurate patient matching between clinic visits, which might occur at different locations and with different care providers.
In the US, exact matching of demographics works about 60% of the time. Probabilistic models work about 80% of the time. South Africa has a similar experience. The end result is that many lab tests are redundant and wasteful. Measuring outcomes is challenging. Closing the loop for followup may be impossible. Biometrics can improve matching to 99%, improving quality, safety and efficiency.
South Africa has a "90/90/90" national strategy - 90% of HIV positive patients should know they are HIV positive. 90% of those should be on anti-retroviral medication. 90% of those should have documented viral suppression with viral load tests.
I've joined an amazing multi-disciplinary team that includes the Gates Foundation, biometric engineers, app developers, usability experts, cloud database/blockchain innovators, and security professionals.
Over the course of 5 days we met with government, academic, and industry leaders throughout South Africa to plan a 2018 pilot of a nationwide patient matching strategy. We've devised objective metrics for success that include improvements in patient and provider satisfaction as well as reductions in total medical expense.
I've written about the Perfect Storm for Innovation. South Africa has all the ingredients - senior leadership of top government healthcare leaders, a guiding coalition of people to oversee the work, appropriate resources to do the work, and an urgency to innovate. I'm hoping that the work in Africa will demonstrate how a nationwide patient matching strategy can work, serving as a model for the world, including the US which continues to struggle i.e. CHIME cancelled its patient matching challenge
The South African people are amazingly kind and helpful. The National Health Laboratory Service has a best in class repository of lab data for the entire country. With Gates funding as a catalyst, I'm convinced we can make a substantial difference in 2018.
In addition to visiting clinics, labs, data centers, hospitals, and IT departments, I had the opportunity to visit an animal sanctuary near the border of Botswana. It's just like Unity Farm Sanctuary except that instead of pig belly rubs, I gave lion belly rubs. An amazing experience.
Unity Farm and Unity Farm Sanctuary Update for November 2017
Starting next month, my daughter Lara will take charge of our instagram, Facebook, and Twitter feeds, providing daily updates about the Farm and Sanctuary. As we approach winter 2017, we can officially declare that the farm and sanctuary are now fully built and we're transitioning to daily operations. We have over 250 animals at this point, all kept healthy, warm and fed every day. Here's a summary of the past month, as told in pictures.
From mid October to early November, the swamp maples, oaks, and poplar take on shades of crimson and bright yellow, turning Unity Lane into the kind road less traveled that Robert Frost wrote about.
Palmer the turkey surveys his empire as the leaves begin to fall. 11 more turkeys have arrived at the Sanctuary and they have designated Palmer as their alpha male.
The five mini-horses weigh about as much as a Great Pyrenees and have all adapted to their new homes. Goldie, an 18 year old stallion, was recently gelded and he'll soon join the others in the main mini-horse paddock
We've finished the cider making for 2017, having harvested 55 different types of apples from the Unity Farm orchard. Our hard cider this year will be a combination of Golden Delicious (sweet), McIntosh (tart), and Macoun (aromatic)
As the temperatures drop below freezing, we're working extra hard to keep every creature fed from the bounty of the fall harvest - apples, pumpkins, and lettuce from the hoop house
We've had our share of animal medical issues - an alpaca with a jaw abscess, a mini-horse with a food impaction, and chickens with eye infections. All have been treated appropriately and thus far, they're recovering. Mocha, the dark brown alpaca is eating again after antibiotics and pain medication for her jaw.
My recent trip to Africa for the Gates Foundation included animal sanctuary visits - just like Unity Farm they have "horses" and guinea fowl.
And pigs with slightly bigger tusks than Tofu the potbelly pig
By Thanksgiving, every night will be below freezing on the farm. The heated buckets are hung, the animal buildings are fortified against the elements, and the food stores are replenished. Let it snow, let it snow, let it snow.
From mid October to early November, the swamp maples, oaks, and poplar take on shades of crimson and bright yellow, turning Unity Lane into the kind road less traveled that Robert Frost wrote about.
Palmer the turkey surveys his empire as the leaves begin to fall. 11 more turkeys have arrived at the Sanctuary and they have designated Palmer as their alpha male.
The five mini-horses weigh about as much as a Great Pyrenees and have all adapted to their new homes. Goldie, an 18 year old stallion, was recently gelded and he'll soon join the others in the main mini-horse paddock
We've finished the cider making for 2017, having harvested 55 different types of apples from the Unity Farm orchard. Our hard cider this year will be a combination of Golden Delicious (sweet), McIntosh (tart), and Macoun (aromatic)
As the temperatures drop below freezing, we're working extra hard to keep every creature fed from the bounty of the fall harvest - apples, pumpkins, and lettuce from the hoop house
We've had our share of animal medical issues - an alpaca with a jaw abscess, a mini-horse with a food impaction, and chickens with eye infections. All have been treated appropriately and thus far, they're recovering. Mocha, the dark brown alpaca is eating again after antibiotics and pain medication for her jaw.
My recent trip to Africa for the Gates Foundation included animal sanctuary visits - just like Unity Farm they have "horses" and guinea fowl.
And pigs with slightly bigger tusks than Tofu the potbelly pig
By Thanksgiving, every night will be below freezing on the farm. The heated buckets are hung, the animal buildings are fortified against the elements, and the food stores are replenished. Let it snow, let it snow, let it snow.
Wednesday, October 25, 2017
Don't Let Things Slip Away From You
Kathy has written this guest post, about the unexpected death of a friend.
"Please don’t let things slip away from you:
first steps,
first kiss,
first real vacation…
first time you know that something is not quite right in your body.
I discovered yesterday that someone about my age whom I have known for at least 15 years had passed away in September. I had seen her once during the summer.
I was told by her colleague that about a year and a half ago, she noticed leaking from one breast. Her coworkers persisted in asking about the situation and she then told them it was just an infection from a cat scratch. It is not clear she ever sought any medical care at that point.
Fast forward to this summer: she developed pneumonia and liver failure, consequently was hospitalized, and all the way to the end she did not acknowledge that the test results showed widespread metastatic breast cancer.
Speaking as a breast cancer patient past my 5 year mark post treatment, none of it was fun or easy, but I bless every day I am given to enjoy my life and family. I think I was so floored by the discovery that my acquaintance had died in a state (MA) where we have had mandatory health insurance for a long time. I have lost other friends to breast cancer, one dying after it infiltrated her brain, but she could never afford health care as a self-employed artist in the era before mandatory health insurance. I know she spent about two years convincing herself nothing was wrong too - until it was too late to do anything.
My father “toughed it out” as he lost weight and grew fatigued. By the time I realized how many pant sizes he had dropped, the neuroendocrine tumor on the head of his pancreas was untreatable. I daily feel robbed of his smile, I am only reassured knowing that he passed so quickly after diagnosis that he never had much time where he was incapacitated.
All this leads to express my hope that if you know something is not quite right in your body, face the risk of getting a diagnosis even when you don’t want to hear the news. Your family and friends want to know you for as long as they can. And cancer therapies and treatments are making amazing advances - while there is life there is hope."
"Please don’t let things slip away from you:
first steps,
first kiss,
first real vacation…
first time you know that something is not quite right in your body.
I discovered yesterday that someone about my age whom I have known for at least 15 years had passed away in September. I had seen her once during the summer.
I was told by her colleague that about a year and a half ago, she noticed leaking from one breast. Her coworkers persisted in asking about the situation and she then told them it was just an infection from a cat scratch. It is not clear she ever sought any medical care at that point.
Fast forward to this summer: she developed pneumonia and liver failure, consequently was hospitalized, and all the way to the end she did not acknowledge that the test results showed widespread metastatic breast cancer.
Speaking as a breast cancer patient past my 5 year mark post treatment, none of it was fun or easy, but I bless every day I am given to enjoy my life and family. I think I was so floored by the discovery that my acquaintance had died in a state (MA) where we have had mandatory health insurance for a long time. I have lost other friends to breast cancer, one dying after it infiltrated her brain, but she could never afford health care as a self-employed artist in the era before mandatory health insurance. I know she spent about two years convincing herself nothing was wrong too - until it was too late to do anything.
My father “toughed it out” as he lost weight and grew fatigued. By the time I realized how many pant sizes he had dropped, the neuroendocrine tumor on the head of his pancreas was untreatable. I daily feel robbed of his smile, I am only reassured knowing that he passed so quickly after diagnosis that he never had much time where he was incapacitated.
All this leads to express my hope that if you know something is not quite right in your body, face the risk of getting a diagnosis even when you don’t want to hear the news. Your family and friends want to know you for as long as they can. And cancer therapies and treatments are making amazing advances - while there is life there is hope."
Saturday, September 16, 2017
Building Unity Farm Sanctuary - September 2017
I’m on a flight to New Zealand as part of my international government service. The 26 hour commute means that even with just two days of meetings in Auckland, I will be gone from the farm for 5 days.
I spent Saturday morning cleaning paddocks, emptying manure carts, packing hay bins, filling water troughs, and doing the final repairs/maintenance that will ensure the farm/sanctuary can thrive for a few days while I’m gone.
What happens at the sanctuary over a typical week?
Numerous volunteers spend time with animals, providing companionship, exercise and socialization
Horse experts bond with Amber, Milly, Grace, and Sweetie, showing them love, respect, and skill as they build enough trust to ride them. Star our donkey has dedicated volunteers that cherish their time with her, and give her the attention she loves, and the exercise with walks that she needs. Donors bring us saddles, bridles, medicine, blankets, and food to keep the horses healthy.
Our friends and colleagues help us create safe living spaces for our animals. Here’s what our equine rescue area looks like today with 8 stall spaces, an acre of paddock supported with heat, power, light, water, and a medical treatment area.
Our agriculture volunteers are helping with apple picking, mushroom log inoculation and harvest. We picked 40 pounds of Shiitake this week. Our 36 different varieties of apples are approaching that perfect picking moment. How do we know? We measure the starch and sugar levels of each tree to decide when to pick. Here’s a great article about the process.
New babies are born every week. Two proud guinea parents brought us a dozen new children which we’re caring for in our brooders.
Just before I left I completed the organic certification for 2017, which is very similar to a Joint Commission visit. The inspector reviewed our entire operation, our record keeping, and our policies. In 2017, we should achieve organic certification for our fruits, vegetables, mushrooms, and compost.
We’re getting very close to completing our Sanctuary building phase - the electrical, plumbing, heating, windows/doors, painting, well systems, irrigation, and gutters/downspouts and fireplaces have all been fixed/maintained. The last project before winter is the generator - a 20kw Generac to ensure the animals have water, light and heat even if winter storms knock out power.
2017 has been an amazing time - a faster pace of change, projects, and activities than Kathy and I every thought possible. As we transition into Fall, we can say with confidence that the 200+ animals at Unity Farm Sanctuary are healthy, supported, and loved. That’s all we could ask for.
Now you know why Kathy and I can never travel together away from the sanctuary. While I’m in New Zealand, she’s running the enterprise. The good news is that we have traveled the world together from 1980 to 2010. At this point, we’re completely comfortable dedicating our lives to our sanctuary work.
Thanks so much to our volunteers, Board of Directors, and community for making it happen.
I spent Saturday morning cleaning paddocks, emptying manure carts, packing hay bins, filling water troughs, and doing the final repairs/maintenance that will ensure the farm/sanctuary can thrive for a few days while I’m gone.
What happens at the sanctuary over a typical week?
Numerous volunteers spend time with animals, providing companionship, exercise and socialization
Horse experts bond with Amber, Milly, Grace, and Sweetie, showing them love, respect, and skill as they build enough trust to ride them. Star our donkey has dedicated volunteers that cherish their time with her, and give her the attention she loves, and the exercise with walks that she needs. Donors bring us saddles, bridles, medicine, blankets, and food to keep the horses healthy.
Our friends and colleagues help us create safe living spaces for our animals. Here’s what our equine rescue area looks like today with 8 stall spaces, an acre of paddock supported with heat, power, light, water, and a medical treatment area.
Our agriculture volunteers are helping with apple picking, mushroom log inoculation and harvest. We picked 40 pounds of Shiitake this week. Our 36 different varieties of apples are approaching that perfect picking moment. How do we know? We measure the starch and sugar levels of each tree to decide when to pick. Here’s a great article about the process.
New babies are born every week. Two proud guinea parents brought us a dozen new children which we’re caring for in our brooders.
Just before I left I completed the organic certification for 2017, which is very similar to a Joint Commission visit. The inspector reviewed our entire operation, our record keeping, and our policies. In 2017, we should achieve organic certification for our fruits, vegetables, mushrooms, and compost.
We’re getting very close to completing our Sanctuary building phase - the electrical, plumbing, heating, windows/doors, painting, well systems, irrigation, and gutters/downspouts and fireplaces have all been fixed/maintained. The last project before winter is the generator - a 20kw Generac to ensure the animals have water, light and heat even if winter storms knock out power.
2017 has been an amazing time - a faster pace of change, projects, and activities than Kathy and I every thought possible. As we transition into Fall, we can say with confidence that the 200+ animals at Unity Farm Sanctuary are healthy, supported, and loved. That’s all we could ask for.
Now you know why Kathy and I can never travel together away from the sanctuary. While I’m in New Zealand, she’s running the enterprise. The good news is that we have traveled the world together from 1980 to 2010. At this point, we’re completely comfortable dedicating our lives to our sanctuary work.
Thanks so much to our volunteers, Board of Directors, and community for making it happen.
Tuesday, September 12, 2017
We Can Improve Care Management
My wife’s cancer treatment, my father’s end of life care, and my own recent primary hypertension diagnosis taught me how we can do better.
Last week, when my wife received a rejection in coverage letter from Harvard Pilgrim/Caremark, it highlighted the imperative we have to improve care management workflow in the US.
Since completing her estrogen positive, progesterone positive, HER2 negative breast cancer treatment in 2012 (chemotherapy, surgery, radiation), she’s been maintained on depot lupron and tamoxifen to suppress estrogen. After three years on a protocol of 22.5mg of lupron every 3 months, her insurer and pharmacy benefits manager decided that 11.25mg was an equally effective dose and sent her a letter telling her they would no longer cover 22.5mg dosing.
Here’s the actual letter she received.
Harvard Pilgrim writes: "HPHC has not made arbitrary decisions on the Lupron dosage for breast cancer, nor with any other policies for that matter. Rather, HPHC has implemented an IV drug management program using the best peer review medical evidence and professional societies guidelines. In the case of oncology drugs, the program has adopted recommendation from the National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 27 leading cancer centers devoted to patient care, research, and education. In Boston, MGH and DF/BW are NCCN member institutions."
Harvard Pilgrim/Caremark was very collaborative in discussing next steps, and I was eager to bring them into the conversation.
There are 5 issues with the letter.
1. Her oncologist was unaware that Harvard Pilgrim/Caremark had such a program. HPHC included an article about the new program in their newsletter and sent email to those clinicians who were likely to be affected. Although a good attempt, those communication modalities did not reach my wife’s oncologist.
2. The rule is stated in a confusing way as "prescriptions for 3.75 mg". How does this relate to my wife’s 22.5mg treatment?
Harvard Pilgrim writes: "Per National Comprehensive Cancer Network guidelines, Lupron 22.5mg is indicated for prostate cancer and not breast cancer. For breast cancer, the guidelines recommend 3.75mg monthly or 11.25mg every three months (a 50% reduction in Kathy’s dose). "
Kathy would have preferred something like ‘national guidelines recommend a 50% reduction in dose to achieve the same outcome with fewer side effects’.
3. Although Kathy’s oncologist is aware of the NCCN guideline, he believes the evidence supporting the guideline is scant (a single paper from 1990), so based on his experience with hundreds of successful cancer patients, he prefers 22.5mg.
Kathy’s oncologist writes: "I think the Dowsett paper—and Mitch is great and a colleague—is a very small 1990 study using 2 doses of lupron in women with metastatic breast cancer. Not very compelling evidence, especially when translated to a different clinical setting. That being said, no one knows for sure what dose is adequate and it probably isn’t the same for all women. In a treat for cure setting, we would rather err on the side of more drug than may be needed in that individual (as it is quite safe) rather than fail to suppress and therefore diminish effectiveness of planned treatment. The absence of menses is not evidence of ovarian suppression since about 20% of women with no periods still have ovarian function."
Harvard Pilgrim writes: "The NCCN guidelines support the 3.75mg IV monthly injections because the 22.5mg depots every three months’ injections do not reliably suppress estrogen in all women, which is the whole point of the treatment There are numerous examples of individual physicians who make assumptions based on their observations and individual experience. In many cases, however, those observations have not been confirmed by future clinical trials and may reflect unconscious bias on the part of the treating physician. Kathy’s oncologist doesn’t appear to have published his observations in a peer review journalwith hundreds of patients using the off-label dose of Lupron 22.5mg every three months. In addition, if he feels strongly that the 22.5 mg is the preferred dose, he has a professional obligation to suggest modifications of the NCCN guidelines. We don’t know if he has made an attempt to modify the NCCN guidelines."
I completely understand Harvard Pilgrim’s motivation to implement a guideline, and NCCN is what is available. The central issue with the letter is not the guidelines themselves, but how the program was implemented before patient/provider educational and workflow concerns had been addressed.
4. The patient is being asked to manage something they lack the expertise to do - bringing together payer medical management and provider caregivers to discuss a medication dose.
Harvard Pilgrim’s writes: "There are many avenues for appeal and the patient is not being asked to manage the process. The contracted provider, who is credentialed by HPHC and who has signed a contract with HPHC, has a responsibility to manage the process by calling the plan or the delegated entity or both, whenever he/she disagree with the initial determination. In addition, the patient and provider can submit a formal appeal requesting an external specialist’s review of the case. In a similar different case to Kathy’s, the external expert in the same specialty (not chosen by the plan), agreed with the NCCN guidelines and HPHC. The match specialist is a board-certified oncologist working at an academic medical center in Pennsylvania. Finally, if the denial is upheld on first level appeal, the patient and physician can appeal to the State. The process is fair and equitable and attempts to balance self-interest and autonomy with common interest and use of evidence-based medicine with the ultimate goal of managing limited resources and continuously increasing care cost in the New England market."
I leave the readers to judge for themselves if the patient is being asked to manage a process.
Harvard Pilgrim writes: "There are many avenues of appeal if the physician does not agree and the physician has a professional responsibility to act as the patient advocate, and to explain to the health plan medical director the rational for supporting a treatment that is not recognized by any of the compendia (Micromedix, Facts and Comparison) and NCCN guidelines."
5. The decision was made without consulting Kathy’s clinical record or cancer treatment protocol. I’ve recently co-authored a book about precision medicine which highlights the need to combine evidence, patient preference, clinical history, genomics, and the experience of other patients to select the right treatments. We all should be working toward that future.
Harvard Pilgrim writes: "While Dr. Halamka is correct that we do not have access to clinical records, in order to ensure that we have relevant information, we ask the treating physician to provide it to us so that we can utilize it in decision-making Participating physicians are asked to fill out a form (designed by the State) and include information relevant to the case. In addition, physicians have the opportunity to call the health plan or the delegated entity and initiate a peer to peer discussion. During the peer to peer discussion, the patient physician has the opportunity to provide the clinical rationale as of why the plan should cover a treatment that deviates from FDA, or other professional guidelines."
Again, I leave it to the readers to decide how a clinician is going to follow that workflow while having 12 minutes to see each patient, comply with Meaningful Use-imposed EHR burdens, be empathic, make eye contact, and never commit malpractice.
Harvard Pilgrim writes: "A physician should never abdicate his/her ethical obligation to support his/her patients in the entire process of care. Many practices delegate certain non-direct patient care functions to other members of the clinical team. However, the physician must always act as patient advocate. In this case, patient advocacy means picking up the phone and having a discussion with a medical director at the Health Plan. . To their credit, many physicians do call the plan and interact with the medical directors."
Sometimes in the healthcare industry we implement changes before policy, technology, and culture are ready. For example, healthcare regulations required encryption of mobile devices before any laptop or phone operating system supported encryption. Meaningful Use tried to accelerate interoperability before we had an electronic provider directory, a nationwide patient matching strategy, or a framework for consistent privacy policy among states. Care management disconnected from clinical workflow has the same problem.
Here are three alternatives which would markedly improve the patient experience
1. The actual Harvard Pilgrim/Caremark formulary is shown below from the e-prescribing function inside my wife’s EHR. I did an eligibility check demonstrating that both Caremark and Medimpact pharmacy benefits mangers consider 22.5 mg a preferred level 1 medication for 3 month administration without any designation that there is a care management decision support rule to consider. Given that Kathy is female and therefore unlikely to have prostate cancer, there is no reason to offer the 22.5mg option. Imagine if during e-prescribing, the rule was displayed/enforced so that 22.5mg wasn’t considered preferred level 1, resulting in a patient/doctor conversation before the medication is ordered.
Harvard Pilgrim writes: "The PBM or Health plan formulary is not designed as a drug management tool. The preferred product designation in the formulary is a cost management tool. The formulary must list all the available dosages so that even an off-label dosage can be dispensed, like in Kathy’s case, as an exception to the medical policy after discussion with the patient physician. Clearly, there is an opportunity to further educate providers on the difference between utilization management and formularies."
2. As a country, we need to finalize the standards for pre-authorization with clinical attachments. Harvard Pilgrim/Caremark could create a rule as part of the pre-authorization workflow. Appropriate clinical documentation would be required before the pre-authorization is approved, again resulting in a patient/doctor conversation before the medication is ordered. Alternatively, the emerging Fast Healthcare Interoperability Resources (FHIR) Clinical Decision Support Hooks specifications will enable EHRs to query cloud hosted clinical rules and display precision medicine information to the provider at the point of care.
3. The letter from Harvard Pilgrim/Caremark, could be revised as follows
'Harvard Pilgrim, Caremark, and your care team work together to keep you healthy. We’re constantly reviewing evidence about the best possible treatments. Based on recent research, it appears you are receiving too high a dose of Depot Lupron, which could cause unwanted side effects. We will contact your doctor and have a discussion about the protocol you are on, taking into account your individual medical history, to collaboratively decide on the best dose for you. We just wanted you to know that in case your prescription changes, it’s all because of new knowledge and experts working together.'
I applaud the intent of care management as a way to improve quality and reduce costs. However, just as with Meaningful Use, I think the letter is a good example of trying to do too much too soon.
I’m not asking that Harvard Pilgrim and Caremark eliminate their care management program. I am asking that they realize the deficiencies of launching a program before the education and workflow redesign efforts were mature, putting the patient in the middle of what should be a payer-provider conversation. The tools to implement that payer-provider conversation don’t yet exist, but soon will and HPHC/Caremark could start by modifying their formularies to offer preferred choices in existing e-prescribing workflows.
As John Kotter taught us in his change management work, we need to follow a process, beginning with a sense of urgency in order to make lasting change. We know that the US must reduce total medical expense while maintaining quality and optimizing outcomes if we are to have a sustainable economic future. Care management based on evidence is the right thing to do. Now we need to work together so that payer systems, decision support rules, and EHRs have a closed loop workflow for all involved. I’m happy to serve on the guiding coalition, along with my colleagues at HPHC, to make this happen.
Thursday, August 17, 2017
Building Unity Farm Sanctuary - August 2017
I’ve put down the pitchfork and shovel, returning to the keyboard to update everyone about our Sanctuary progress. Here’s what’s happened over the past few weeks.
As Kathy wrote on Facebook on July 25, Pippin, our 30 year old Welsh Pony passed away from cancer. His last few months included daily play with three other ponies, walks in the woods, and generous servings of grain/treats. He was the centerpiece of our horse work at the sanctuary and we miss him every day. He’s buried on a hill covered with oaks overlooking the barnyard marked by a large flat stone.
The sanctuary volunteer program now includes over 20 people who feed, bathe, exercise, socialize and medicate all the inhabitants of the sanctuary. We also have volunteers helping out with the agricultural duties - harvesting, planting, and weeding. This amazing outpouring of support from the community enables Kathy and I to keep everything (well almost everything) on track.
The new paddocks are almost done and we’ve officially begun placing the half mile of fencing around the new run ins. After Labor Day, we’ll have enough capacity to take on a small herd of mini-horses, pictured below. Between the sanctuary and farm we’ll have 20 stalls and 10 paddocks. With help from a local excavator, we’ve dug the trenches and laid the pipe/wire so that each stall has heated buckets, lighting, and easy access to water.
Lunchbox Benson, a vietnamese pot belly pig, nipped one of our volunteers on her ankle. We flushed the area to ensure it was clean enough to bandage and sent her for medical followup. Lunchbox has never shown any unsociable behavior, so we’re concerned that one of his tusks may be growing into his palate, making him defensive. We’re searching for a vet with experience in pig dentistry - not an easy task.
Over the next month, the pace of farm activities will continue at a fever pitch as we harvest the remaining summer fruits/vegetables, garlic, plant the fall/winter crops, and begin preparation for winter. All our construction and improvement projects will wrap up in September. As Kathy and I joke, when we’re 64 in 9 years, the daily heavy lifting will need to slow down. (And Kathy assures me that she’ll still need me and will still feed me)
We set the foundation for the Unity Farm sanctuary flagpole this morning - a 25 foot fiberglass single piece that is weather resistant and will not attract lightening. Kathy has designed the sanctuary flag that we’ll fly.
As a place of peace and protection, the Sanctuary continues to be a haven for local wildlife. Yesterday, a dozen wild turkeys visited Star the donkey. Thus far, all the local animals - coyotes, foxes, fisher cats, raccoons, possums, skunks, hawks, turkeys and deer pass the through the sanctuary every day without a problem. There must be something about the environment which encourages good behavior.
The carriage house refinishing project is now finished, complete with a coat of USDA approved epoxy on the floors.
We’ve just completed our 2017 organic certification, following all the rules and documenting our compliance with organic best practices. The onsite unannounced inspection will happen soon.
The rainy summer has produced a bountiful Shiitake mushroom crop and we picked 40 pounds last week. We’ve delivered fresh organic mushrooms, cucumbers, basil, and lettuce to Tilly and Salvy’s farmstand in Natick.
Hopefully this gives you a sense of everything that has consumed us nights and weekends, reducing my writing time. I promise to do better in the Fall!
As Kathy wrote on Facebook on July 25, Pippin, our 30 year old Welsh Pony passed away from cancer. His last few months included daily play with three other ponies, walks in the woods, and generous servings of grain/treats. He was the centerpiece of our horse work at the sanctuary and we miss him every day. He’s buried on a hill covered with oaks overlooking the barnyard marked by a large flat stone.
The sanctuary volunteer program now includes over 20 people who feed, bathe, exercise, socialize and medicate all the inhabitants of the sanctuary. We also have volunteers helping out with the agricultural duties - harvesting, planting, and weeding. This amazing outpouring of support from the community enables Kathy and I to keep everything (well almost everything) on track.
Lunchbox Benson, a vietnamese pot belly pig, nipped one of our volunteers on her ankle. We flushed the area to ensure it was clean enough to bandage and sent her for medical followup. Lunchbox has never shown any unsociable behavior, so we’re concerned that one of his tusks may be growing into his palate, making him defensive. We’re searching for a vet with experience in pig dentistry - not an easy task.
Over the next month, the pace of farm activities will continue at a fever pitch as we harvest the remaining summer fruits/vegetables, garlic, plant the fall/winter crops, and begin preparation for winter. All our construction and improvement projects will wrap up in September. As Kathy and I joke, when we’re 64 in 9 years, the daily heavy lifting will need to slow down. (And Kathy assures me that she’ll still need me and will still feed me)
We set the foundation for the Unity Farm sanctuary flagpole this morning - a 25 foot fiberglass single piece that is weather resistant and will not attract lightening. Kathy has designed the sanctuary flag that we’ll fly.
As a place of peace and protection, the Sanctuary continues to be a haven for local wildlife. Yesterday, a dozen wild turkeys visited Star the donkey. Thus far, all the local animals - coyotes, foxes, fisher cats, raccoons, possums, skunks, hawks, turkeys and deer pass the through the sanctuary every day without a problem. There must be something about the environment which encourages good behavior.
The carriage house refinishing project is now finished, complete with a coat of USDA approved epoxy on the floors.
We’ve just completed our 2017 organic certification, following all the rules and documenting our compliance with organic best practices. The onsite unannounced inspection will happen soon.
The rainy summer has produced a bountiful Shiitake mushroom crop and we picked 40 pounds last week. We’ve delivered fresh organic mushrooms, cucumbers, basil, and lettuce to Tilly and Salvy’s farmstand in Natick.
Hopefully this gives you a sense of everything that has consumed us nights and weekends, reducing my writing time. I promise to do better in the Fall!
Sunday, August 6, 2017
Unity Farm and Sanctuary Guest Post
Over the past few weeks I've been writing a few journal articles and finishing a book, so my blog posts have waned. They will start again soon. In the meantime, my mother is visiting and here is her guest post.
Dagmar Halamka's farm notes from August 4,2017 and August 5, 2017.
The beauty here is infinite - wildflowers everywhere, gushing fountains in ponds with swimming ducks and geese and vast amounts of greenery because of the frequent rain. 60 acres of enchanted forest that even "House and Garden" magazine could not duplicate surround the farm. Roosters begin crowing about 4:30am. A very slow moving freight train provides a marvelous whistle several times a day as it moves through the countryside.
Today was Blueberry picking day at Unity Farm. It’s hard work! An hour and a half of picking rendered one bucket (I ate a "few"). I am renegotiating my contract!
Palmer, the turkey, followed us around all day - wherever we went. He extends his plumage often so we can admire how grand he is. When I returned with the blueberries, ALL the geese greeted me with extensive honks (males) and hinks (females). I think they believed I had food for them.
Then planting time arrived - I planted 45 lettuce seeds. Really easy since John had already provided the soil blocks.
We streamed "Lion" yesterday evening. I highly recommend it. A beautiful story with an
endearing plot theme.
We visited the new "age restricted" (over 55) condominiums at Abbey Road - just 500 yards from Unity Farm on the trails through the sanctuary. I was immediately surprised by the Revolutionary War era cemetery in the front of the development.
Tuesday, the local Garden club will come to Unity Farm for a potluck. Kathy admitted they will
market living in Sherborn to me.
I decided to walk to the post office. I was sauntering back when a torrential rainstorm appeared, seemingly out of nowhere. Kathy drove down in the car and truly rescued me.
Dinner with John’s daughter was at a Japanese restaurant in Wellesley. They lived
there before moving to Sherborn. So it has sentimental memories for her.
More tomorrow.
Dagmar Halamka's farm notes from August 4,2017 and August 5, 2017.
The beauty here is infinite - wildflowers everywhere, gushing fountains in ponds with swimming ducks and geese and vast amounts of greenery because of the frequent rain. 60 acres of enchanted forest that even "House and Garden" magazine could not duplicate surround the farm. Roosters begin crowing about 4:30am. A very slow moving freight train provides a marvelous whistle several times a day as it moves through the countryside.
Today was Blueberry picking day at Unity Farm. It’s hard work! An hour and a half of picking rendered one bucket (I ate a "few"). I am renegotiating my contract!
Palmer, the turkey, followed us around all day - wherever we went. He extends his plumage often so we can admire how grand he is. When I returned with the blueberries, ALL the geese greeted me with extensive honks (males) and hinks (females). I think they believed I had food for them.
Then planting time arrived - I planted 45 lettuce seeds. Really easy since John had already provided the soil blocks.
We streamed "Lion" yesterday evening. I highly recommend it. A beautiful story with an
endearing plot theme.
We visited the new "age restricted" (over 55) condominiums at Abbey Road - just 500 yards from Unity Farm on the trails through the sanctuary. I was immediately surprised by the Revolutionary War era cemetery in the front of the development.
Tuesday, the local Garden club will come to Unity Farm for a potluck. Kathy admitted they will
market living in Sherborn to me.
I decided to walk to the post office. I was sauntering back when a torrential rainstorm appeared, seemingly out of nowhere. Kathy drove down in the car and truly rescued me.
Dinner with John’s daughter was at a Japanese restaurant in Wellesley. They lived
there before moving to Sherborn. So it has sentimental memories for her.
More tomorrow.
Thursday, July 6, 2017
Reflections on the US HIT Policy Trajectory
I’m in China this week, meeting with government, academia, and industry leaders in Guangzhou, Shenzhen, Beijing, Shanghai, and Suzhou. The twelve hour time difference means that I can work a day in China, followed by a day in Boston. For the next 7 days, I’ll truly be living on both sides of the planet.
I recently delivered this policy update about the key developments in healthcare IT policy and sentiment over the past 90 days.
I’ve not written a specific summary of the recently released Quality Patient Program proposed rule which provides the detailed regulatory guidance for implementation of MACRA/MIPS, but here’s the excellent 26 page synopsis created by CMS which provides an overview of the 1058 page rule.
In general, it has many positive provisions.
The industry is welcoming the delays and accommodations it includes, especially the use of 2014 certified records for the 2018 year and the small practice exemptions which recognize the technologies/people/processed needed to succeed under MACRA/MIPS could overwhelm independent clinicians.
The Senate replacement for the Affordable Care Act continues to be debated and there is concern that loss of medicaid dollars may eliminate funding streams that supported healthcare IT. It’s too early to tell where the ACA repeal/replace activity will converge.
What can we say about the IT policy direction of the US right now?
1. There seems to be great consensus that all stakeholders need to focus on enhancing interoperability technology and policy in support of care coordination, population health, precision medicine, patient/family engagement, and research.
2. There is also a consensus that usability of the IT tools in the marketplace needs to be enhanced. Although the major EHR vendors are working on usability improvements, I believe the greatest agility will come from startup community via apps that get/put data with EHRs using APIs based on evolving FHIR standards. Here’s my sense of each vendor’s approach
Epic - will support open source FHIR APIs at no cost for the use cases prioritized by the Argonaut working group and HL7. Will also support proprietary Epic APIs for Epic licensees.
Cerner - similar to Epic with additional SMART on FHIR support
Meditech - will support open source FHIR APIs and give encourage developers to work with customers to leverage the SQL-based Meditech data repository at each customer site.
Athena - will support open source FHIR APIs at no cost but give much more sophisticated workflow integration through the more disruption please program, which involves revenue sharing with developers.
eCW - the department of justice settle should lead to additional eCW support for standards based data exchange.
3. Many organizations in industry, government, and academic are thinking about patient identity strategies. It’s too early to know what solutions will predominate but leading contenders are biometrics (fingerprint, image recognition, palm vein geometry etc.), a voluntary national identifier issued by some authority (public or private sector), or some creative software solution such as OAuth/OpenID/Blockchain etc. In July, I will co-chair a national consensus conference on patient identifiers hosted by the Pew Charitable Trust. I’m hoping we achieve consensus on a framework that accelerates the availability of such an identifier for multiple purposes.
4. Several groups are thinking about how best to converge our heterogenous state privacy policies, specifically focusing on the role of the patient as data steward. We can radically simplify privacy protection if the patient is the agent by which information is shared.
5. Finally, there seems to be an overwhelming sentiment that the concept of certification and prescriptive IT policy should be replaced by an outcomes focus. Rather than counting the number of Direct messages sent, giving organizations the flexibility to each data using the the most locally appropriate technology but then holding them accountable for a result of that data exchange i.e. reduced readmissions, reduced redundant testing, reduced errors seems to be well aligned with a move to value-based purchasing.
In theory the members of the new Healthcare Information Technology Advisory Standards Committee (which replaces the former Policy and Standards Committees) will be named in July. I look forward to hearing about the initial challenges the group will tackle. I’m hopeful they will choose some of the issues mentioned above.
In several recent lectures, I’ve reinforced my optimism for the future of the healthcare IT ecosystem. I believe the next few years will be filled with market driven innovation, encouraged by new consumer demand for healthcare process automation and supplemented by low cost, cloud based utility devices such as the machine learning and image recognition APIs offered by Google and Amazon. It will be a great time for entrepreneurs, providers, and patients, all of whom are fatigued after years of Meaningful Use, ICD10, and accelerating numbers of quality measures. As a CIO, I’m looking forward to doing what my customers want me to do instead of being told what I must do.
I recently delivered this policy update about the key developments in healthcare IT policy and sentiment over the past 90 days.
I’ve not written a specific summary of the recently released Quality Patient Program proposed rule which provides the detailed regulatory guidance for implementation of MACRA/MIPS, but here’s the excellent 26 page synopsis created by CMS which provides an overview of the 1058 page rule.
In general, it has many positive provisions.
The industry is welcoming the delays and accommodations it includes, especially the use of 2014 certified records for the 2018 year and the small practice exemptions which recognize the technologies/people/processed needed to succeed under MACRA/MIPS could overwhelm independent clinicians.
The Senate replacement for the Affordable Care Act continues to be debated and there is concern that loss of medicaid dollars may eliminate funding streams that supported healthcare IT. It’s too early to tell where the ACA repeal/replace activity will converge.
What can we say about the IT policy direction of the US right now?
1. There seems to be great consensus that all stakeholders need to focus on enhancing interoperability technology and policy in support of care coordination, population health, precision medicine, patient/family engagement, and research.
2. There is also a consensus that usability of the IT tools in the marketplace needs to be enhanced. Although the major EHR vendors are working on usability improvements, I believe the greatest agility will come from startup community via apps that get/put data with EHRs using APIs based on evolving FHIR standards. Here’s my sense of each vendor’s approach
Epic - will support open source FHIR APIs at no cost for the use cases prioritized by the Argonaut working group and HL7. Will also support proprietary Epic APIs for Epic licensees.
Cerner - similar to Epic with additional SMART on FHIR support
Meditech - will support open source FHIR APIs and give encourage developers to work with customers to leverage the SQL-based Meditech data repository at each customer site.
Athena - will support open source FHIR APIs at no cost but give much more sophisticated workflow integration through the more disruption please program, which involves revenue sharing with developers.
eCW - the department of justice settle should lead to additional eCW support for standards based data exchange.
3. Many organizations in industry, government, and academic are thinking about patient identity strategies. It’s too early to know what solutions will predominate but leading contenders are biometrics (fingerprint, image recognition, palm vein geometry etc.), a voluntary national identifier issued by some authority (public or private sector), or some creative software solution such as OAuth/OpenID/Blockchain etc. In July, I will co-chair a national consensus conference on patient identifiers hosted by the Pew Charitable Trust. I’m hoping we achieve consensus on a framework that accelerates the availability of such an identifier for multiple purposes.
4. Several groups are thinking about how best to converge our heterogenous state privacy policies, specifically focusing on the role of the patient as data steward. We can radically simplify privacy protection if the patient is the agent by which information is shared.
5. Finally, there seems to be an overwhelming sentiment that the concept of certification and prescriptive IT policy should be replaced by an outcomes focus. Rather than counting the number of Direct messages sent, giving organizations the flexibility to each data using the the most locally appropriate technology but then holding them accountable for a result of that data exchange i.e. reduced readmissions, reduced redundant testing, reduced errors seems to be well aligned with a move to value-based purchasing.
In theory the members of the new Healthcare Information Technology Advisory Standards Committee (which replaces the former Policy and Standards Committees) will be named in July. I look forward to hearing about the initial challenges the group will tackle. I’m hopeful they will choose some of the issues mentioned above.
In several recent lectures, I’ve reinforced my optimism for the future of the healthcare IT ecosystem. I believe the next few years will be filled with market driven innovation, encouraged by new consumer demand for healthcare process automation and supplemented by low cost, cloud based utility devices such as the machine learning and image recognition APIs offered by Google and Amazon. It will be a great time for entrepreneurs, providers, and patients, all of whom are fatigued after years of Meaningful Use, ICD10, and accelerating numbers of quality measures. As a CIO, I’m looking forward to doing what my customers want me to do instead of being told what I must do.
Sunday, July 2, 2017
Building Unity Farm Sanctuary - First Week of July 2017
Admittedly, the pace of my writing has slowed this Summer since each day is filled with a combination of IT work, mentoring, and keeping 60 acres of farm/sanctuary running smoothly. How’s it all going? Our trajectory is good.
So much of what we’re doing at the farm/sanctuary is improvisation that we have no choice but to create a vision and accept ambiguity on the daily journey.
We received a request to adopt a house pig - Rue, who’s 80 pounds at 4 years old and extremely well behaved. We’ve been socializing her with the other pigs and thus far, all is proceeding as expected - they challenge each other across a fence and eventually accept their place in the social hierarchy. Now that we have 5 pigs, the question we asked is what is their ideal living arrangement - how can we create a pig “condo complex” that works in summer and winter for everyone.
Sometimes a sense of urgency is needed to motivate change. We have 8 baby turkeys and they needed a safe outdoor home. Although we built an aviary last year, Penny, the Yorkshire pig, was living in the aviary at night because she was not ready to spend the night with Tofu and Lunchbox, the pot belly pigs. Although we knew it would cause one night of anxiety, we put all of them together in a paddock and gave Penny a separate crate so that she could have a private space. After a few nights, she began sleeping with the other pigs and now all of them cluster in a single pig pile, completely happy together. The empty aviary became the home for the baby turkeys.
We put Rue and Hazel together in a paddock separated by fence. At this point they are rubbing noses and not fighting. After another month, we’ll take down the fence.
The new arrangement - 3 pigs living in one paddock and 2 pigs living in another - completely supports our daily routines and workflow. The farm is a continuous experiment and this time it all worked.
Similarly, it’s clear that our 5 horses will have a natural grouping - the dominant Arabian (Amber) and the assertive Welsh Pony (Sweetie) will get along perfectly. The older Welsh Pony (Pippin), the shy Welsh Pony (Grace), and the good natured Welsh Pony (Millie) will be a perfect herd.
Our new paddocks and run ins are progressing well. The horse groups above will occupy two paddocks, we’ll leave one paddock open for exercising/running, and leave a paddock for whatever flexibility we need to continue our sanctuary mission.
The last experimental animal grouping that is working very well is the combination of goats and a donkey. Star the donkey is doing well on her diet/exercise program and after a year, she’ll have a healthy weight. The goats can eat her food but she cannot eat the goats food. They keep each other company and are very happy.
If you asked me a few years ago if we would be the stewards of horses, donkeys, pigs, llamas, alpacas, geese, ducks, chickens, guinea fowl turkeys, Great Pyrenees and bees, I would have questioned your sanity. Now every creature is part of the daily fabric of our lives and we treasure all of them.
The Sanctuary volunteer program is in full gear with multiple people donating time to the sanctuary every day. They are grooming horses, walking the donkey, feeding poultry, cleaning paddocks, and socializing with the pigs. The sanctuary has become such a community destination that there is not a moment of private time left on the property - and we’re ok with that. My advice to our family - always stay dressed!
A mother rabbit had a litter of 4 babies in the middle of the orchard. I did not realize that rabbits create hidden burrows in grasslands so that their young are just under the surface. While walking through the orchard I heard a squeak and picked up the baby pictured below - I returned her immediately to her mother and the family in the rabbit den.
It’s early Summer harvest time and we’ve picked a few hundred heads of lettuce, 4 beds of basil, strawberries, cucumbers, and peas. Garlic, tomatoes, and peppers are next in line.
Will I ever have time to continue the volume of writing I once did? As building the sanctuary and nursing the animals back to health is replaced with maintaining the sanctuary and helping the animals thrive, there is a certain routine that will return to each day. Waking up a dawn, feeding/watering, walking, cleaning, and medications takes about 2 hours. Then comes, the work day. Evening chores to prepare everyone for a safe and quiet night takes about 2 hours. It’s common for Kathy and I to sit down for the first time each day at 9pm. As I reflect on this stage of life - 33 years of marriage, 20 years as a CIO, and a married daughter living in her own household - having the joyful chaos of the farm and sanctuary 7x24x365 is exactly right.
So much of what we’re doing at the farm/sanctuary is improvisation that we have no choice but to create a vision and accept ambiguity on the daily journey.
We received a request to adopt a house pig - Rue, who’s 80 pounds at 4 years old and extremely well behaved. We’ve been socializing her with the other pigs and thus far, all is proceeding as expected - they challenge each other across a fence and eventually accept their place in the social hierarchy. Now that we have 5 pigs, the question we asked is what is their ideal living arrangement - how can we create a pig “condo complex” that works in summer and winter for everyone.
Sometimes a sense of urgency is needed to motivate change. We have 8 baby turkeys and they needed a safe outdoor home. Although we built an aviary last year, Penny, the Yorkshire pig, was living in the aviary at night because she was not ready to spend the night with Tofu and Lunchbox, the pot belly pigs. Although we knew it would cause one night of anxiety, we put all of them together in a paddock and gave Penny a separate crate so that she could have a private space. After a few nights, she began sleeping with the other pigs and now all of them cluster in a single pig pile, completely happy together. The empty aviary became the home for the baby turkeys.
We put Rue and Hazel together in a paddock separated by fence. At this point they are rubbing noses and not fighting. After another month, we’ll take down the fence.
The new arrangement - 3 pigs living in one paddock and 2 pigs living in another - completely supports our daily routines and workflow. The farm is a continuous experiment and this time it all worked.
Similarly, it’s clear that our 5 horses will have a natural grouping - the dominant Arabian (Amber) and the assertive Welsh Pony (Sweetie) will get along perfectly. The older Welsh Pony (Pippin), the shy Welsh Pony (Grace), and the good natured Welsh Pony (Millie) will be a perfect herd.
Our new paddocks and run ins are progressing well. The horse groups above will occupy two paddocks, we’ll leave one paddock open for exercising/running, and leave a paddock for whatever flexibility we need to continue our sanctuary mission.
The last experimental animal grouping that is working very well is the combination of goats and a donkey. Star the donkey is doing well on her diet/exercise program and after a year, she’ll have a healthy weight. The goats can eat her food but she cannot eat the goats food. They keep each other company and are very happy.
If you asked me a few years ago if we would be the stewards of horses, donkeys, pigs, llamas, alpacas, geese, ducks, chickens, guinea fowl turkeys, Great Pyrenees and bees, I would have questioned your sanity. Now every creature is part of the daily fabric of our lives and we treasure all of them.
The Sanctuary volunteer program is in full gear with multiple people donating time to the sanctuary every day. They are grooming horses, walking the donkey, feeding poultry, cleaning paddocks, and socializing with the pigs. The sanctuary has become such a community destination that there is not a moment of private time left on the property - and we’re ok with that. My advice to our family - always stay dressed!
A mother rabbit had a litter of 4 babies in the middle of the orchard. I did not realize that rabbits create hidden burrows in grasslands so that their young are just under the surface. While walking through the orchard I heard a squeak and picked up the baby pictured below - I returned her immediately to her mother and the family in the rabbit den.
It’s early Summer harvest time and we’ve picked a few hundred heads of lettuce, 4 beds of basil, strawberries, cucumbers, and peas. Garlic, tomatoes, and peppers are next in line.
Will I ever have time to continue the volume of writing I once did? As building the sanctuary and nursing the animals back to health is replaced with maintaining the sanctuary and helping the animals thrive, there is a certain routine that will return to each day. Waking up a dawn, feeding/watering, walking, cleaning, and medications takes about 2 hours. Then comes, the work day. Evening chores to prepare everyone for a safe and quiet night takes about 2 hours. It’s common for Kathy and I to sit down for the first time each day at 9pm. As I reflect on this stage of life - 33 years of marriage, 20 years as a CIO, and a married daughter living in her own household - having the joyful chaos of the farm and sanctuary 7x24x365 is exactly right.
Thursday, June 8, 2017
Building Unity Farm Sanctuary - Second Week of June 2017
Star the Donkey arrived at the Sanctuary last week and she’s living with the goats, serving as a livestock guardian. She’s 18 years old (donkeys live to 35) is about 100 pounds overweight. We’ll be restricting her diet, giving her daily exercise, and provide intensive veterinary care until her weight normalizes. I expect that will take a year or two. Her first vet visit and farrier (hoof) work will be this week.
Honey the chicken develop wheezing this week and we’ve isolated her from the flock. Although she has intermittent breathing issues, she’s eating, laying eggs, and acting normally. We’re not sure if its viral, bacterial, parasitic, or structural, but we’ll continue to isolate and observe her.
Dr. Henry Feldman from BIDMC brought us an unusual gift this week - a laser cut holder for Unity Farm Cider and Honey Lager. He made it on his Glowforge, a 3D laser printer. The precision is amazing. Here’s a video showing how it works.
Work on the sanctuary continues. This week we replaced the toilets with modern low volume models from Toto so now we have highly reliable bathrooms for guests, visitors, and events. We’re continuing work on the water system and all plumbing from well head to house distribution should be replaced by next week.
It’s been raining non-stop for the past week and we’ve been doing our best to keep the animals warm and dry. Palmer the Turkey has learned to sleep indoors on rainy nights but most of all he loves his humans.
As the mud dries we’ll continue to add stone dust to the new paddocks and build fences. By July we should be ready for the four new 12x20 run ins.
This weekend I’ll continue our Spring program of trail mowing and maintenance. At this point, that means nearly 3 miles of work as listed below. At the end of mowing 3 miles of trail, Ibuprofen is your best friend.
On the Unity Farm property, 6000 feet
Woodland trail 950 feet
Barn road 250 feet
Mushroom trail 250 feet
Orchard road 350 feet
Old Cart path 600 feet
Marsh trail 850 feet
Unity Lane 500 feet
Driveway 500 feet
Orchard trail 800 feet
Gate trail 450 feet
Forget me not glen 200 feet
Cattail hollow 50 feet
Momiji Matsu trail 250 feet
On the Sanctuary property, 2640 feet
Pine loop 600 feet
Pond trail 250 feet
Portion of Upper Meadow trail 400 feet
Coyote Run trail 400 feet
Treehouse trail 150 feet
Paddock trails (TBD) 840 feet
On the rural land foundation property, 5400 feet
Green Lane trail 1050 feet
Brook path 800 feet
Cattail loop 1800 feet
Lower Meadow trail 450 feet
Zions Lane 450 feet
Portion of Upper Meadow trail 850 feet
Honey the chicken develop wheezing this week and we’ve isolated her from the flock. Although she has intermittent breathing issues, she’s eating, laying eggs, and acting normally. We’re not sure if its viral, bacterial, parasitic, or structural, but we’ll continue to isolate and observe her.
Dr. Henry Feldman from BIDMC brought us an unusual gift this week - a laser cut holder for Unity Farm Cider and Honey Lager. He made it on his Glowforge, a 3D laser printer. The precision is amazing. Here’s a video showing how it works.
Work on the sanctuary continues. This week we replaced the toilets with modern low volume models from Toto so now we have highly reliable bathrooms for guests, visitors, and events. We’re continuing work on the water system and all plumbing from well head to house distribution should be replaced by next week.
It’s been raining non-stop for the past week and we’ve been doing our best to keep the animals warm and dry. Palmer the Turkey has learned to sleep indoors on rainy nights but most of all he loves his humans.
As the mud dries we’ll continue to add stone dust to the new paddocks and build fences. By July we should be ready for the four new 12x20 run ins.
This weekend I’ll continue our Spring program of trail mowing and maintenance. At this point, that means nearly 3 miles of work as listed below. At the end of mowing 3 miles of trail, Ibuprofen is your best friend.
On the Unity Farm property, 6000 feet
Woodland trail 950 feet
Barn road 250 feet
Mushroom trail 250 feet
Orchard road 350 feet
Old Cart path 600 feet
Marsh trail 850 feet
Unity Lane 500 feet
Driveway 500 feet
Orchard trail 800 feet
Gate trail 450 feet
Forget me not glen 200 feet
Cattail hollow 50 feet
Momiji Matsu trail 250 feet
On the Sanctuary property, 2640 feet
Pine loop 600 feet
Pond trail 250 feet
Portion of Upper Meadow trail 400 feet
Coyote Run trail 400 feet
Treehouse trail 150 feet
Paddock trails (TBD) 840 feet
On the rural land foundation property, 5400 feet
Green Lane trail 1050 feet
Brook path 800 feet
Cattail loop 1800 feet
Lower Meadow trail 450 feet
Zions Lane 450 feet
Portion of Upper Meadow trail 850 feet
Wednesday, May 31, 2017
What’s Next for Electronic Health Records?
With the Department of Justice announcement of the $155 million dollar eClinicalWorks settlement (including personal liability for the CEO, CMO and COO), many stakeholders are wondering what’s next for EHRs.
Clearly the industry is in a state of transition. eCW will be distracted by its 5 year corporate integrity agreement. AthenaHealth will have to focus on the activist investors at Elliott Management who now own 10% of the company and have a track record of changing management/preparing companies for sale. As mergers and acquisitions result in more enterprise solutions, Epic (and to some extent Cerner) will displace other vendors in large healthcare systems. However, the ongoing operational cost of these enterprise solutions will cause many to re-examine alternatives such as Meditech.
As an engineer, I select products and services based on requirements and not based on marketing materials, procurements by other local institutions, or the sentiment that “no one gets fired by buying vendor X”.
I have a sense that EHR requirements are changing and we’re in transition from EHR 1.0 to EHR 2.0. Here’s what I’m experiencing:
1. (Fewer government mandates) The era of prescriptive government regulation requiring specific EHR functionality is ending. In my conversations with government (executive branch, legislative branch), providers/payers, and academia, I’ve heard over and over that it is better to focus on results achieved than to do something like count the number the CCDA documents sent via the Direct protocol. If you want to use mobile devices to monitor patients in their homes - great! If you want to use telemedicine to do wellness checks - great! If you want to send off duty EMS workers using iPads to evaluate the activities of daily living for elderly patients - great! Reducing hospital readmissions is the goal and there are many enabling technologies. Suggesting that one size fits all in every geography for every patient no longer works as we move from a data recording focus (EHR 1.0) to an outcomes focus (EHR 2.0)
2. (Team-based care) Clinicians can no longer get through their day when the requirements are to see a patient every 15 minutes, enter 140 structured data elements, submit 40 quality measures, satisfy the patient, and never commit malpractice. A team of people is needed to maintain health and a new generation of communication tools is needed to support clinical groupware. This isn’t just HIPAA compliant messaging. We need workflow integration, rules based escalation of messages, and routing based on time of day/location/schedules/urgency/licensure. We need automated clinical documentation tools that record what each team member does and then requires a review/signoff by an accountable professional, not writing War and Peace from scratch until midnight (as is the current practice for many primary care clinicians)
3. (Value-based purchasing) Fee for service is dying and is being replaced by alternative quality contracts based on risk sharing.
Dr. Allan H. Goroll’s excellent New England Journal of Medicine article notes that EHR 1.0 has achieved exactly the result that historical regulation has required - a tool that supports billing and government reporting - not clinician and patient satisfaction.
Our electronic tools for EHR 2.0 should include the functionality necessary to document care plans, variation from those plans, and outcomes reported from patient generated healthcare data. Components of such software would include the elements that compromise the “Care Management Medical Record” - enrolling patients in protocols based on signs/symptoms/diagnosis, then using customer relationship management concepts to ensure patients receive the services recommended.
ICD-10, CPT, and HCPCS would no longer be necessary. Bills will no longer be generated. Payments would be fixed per patient per year and all care team members would be judged on wellness achieved for total medical expense incurred. SNOMED-CT would be the vocabulary used to record clinical observations for quality measurement.
4. (Usability) I do not fault EHR developers for the lack of usability in medical software. They were given thousands of pages of regulations then told to author new software, certify it, and deploy it in 18 months. I call this the “ask 9 women to have a baby in 1 month” concept, since Meaningful Use timeframes violated the “gestation period” for innovation. How can we achieve better usability in the future? My view is that EHRs are platforms (think iPhone) and legions of entrepreneurs creating add on functionality author the apps that run on that platform. Every week, I work with young people creating the next generation of highly usable clinical functionality that improves usability. They need to be empowered to get/put data from EHR platforms and emerging FHIR standards will help with that.
I was recently asked to define HIT innovation. I said it was the novel application of people, processes and technologies to improve quality, safety and efficiency. Creating modules that layer on top of existing EHR transactional systems embraces this definition.
5. (Consumer driven) In a recent keynote, I joked that my medical school training (30 years ago) in customer service mirrored that provided by the US domestic airlines. Healthcare experiences can be like boarding a crowded aircraft where your presence is considered an inconvenience to the staff. We’re entering a new era with evolving models that are moving care to the home including internet of things monitoring, supporting convenient ambulatory locations near you, offering urgent care clinics with long hours, enabling electronic self scheduling, and encouraging virtual visits. Although existing EHR 1.0 products have patient portals, they have not made the patient/family an equal member of the care team, providing them with care navigation tools. BIDMC is working on an Amazon Echo/Alexa service backed by microservices/Bots that brings ambient listening technologies to the home for coordination with care teams. When see you articles like this one, you know that the technology tools we have to support patients as consumers are not yet sufficient.
The US has been working on EHR 1.0 for a long time. 57 years ago, the New England Deaconess computerized its pharmacy using an IBM Mainframe. Here’s the original document from 1960 describing the achievement. Of note, the document highlights that the overall hospital budget reached a new high - $5.4 million and the increased salary, clinical care and IT expense meant that hospital rates would have to be raised to $25/bed/day. After nearly six decades of work on EHR 1.0, let’s declare victory and move onto social networking-like groupware supporting teams of caregivers focused on value while treating patients as customers using mobile and ambient listening tools. Government and private payers need to align incentives to support this future based on outcomes, putting the era of prescriptive EHR 1.0 functionality (and the energy enforcing the regulations) behind us.
Clearly the industry is in a state of transition. eCW will be distracted by its 5 year corporate integrity agreement. AthenaHealth will have to focus on the activist investors at Elliott Management who now own 10% of the company and have a track record of changing management/preparing companies for sale. As mergers and acquisitions result in more enterprise solutions, Epic (and to some extent Cerner) will displace other vendors in large healthcare systems. However, the ongoing operational cost of these enterprise solutions will cause many to re-examine alternatives such as Meditech.
As an engineer, I select products and services based on requirements and not based on marketing materials, procurements by other local institutions, or the sentiment that “no one gets fired by buying vendor X”.
I have a sense that EHR requirements are changing and we’re in transition from EHR 1.0 to EHR 2.0. Here’s what I’m experiencing:
1. (Fewer government mandates) The era of prescriptive government regulation requiring specific EHR functionality is ending. In my conversations with government (executive branch, legislative branch), providers/payers, and academia, I’ve heard over and over that it is better to focus on results achieved than to do something like count the number the CCDA documents sent via the Direct protocol. If you want to use mobile devices to monitor patients in their homes - great! If you want to use telemedicine to do wellness checks - great! If you want to send off duty EMS workers using iPads to evaluate the activities of daily living for elderly patients - great! Reducing hospital readmissions is the goal and there are many enabling technologies. Suggesting that one size fits all in every geography for every patient no longer works as we move from a data recording focus (EHR 1.0) to an outcomes focus (EHR 2.0)
2. (Team-based care) Clinicians can no longer get through their day when the requirements are to see a patient every 15 minutes, enter 140 structured data elements, submit 40 quality measures, satisfy the patient, and never commit malpractice. A team of people is needed to maintain health and a new generation of communication tools is needed to support clinical groupware. This isn’t just HIPAA compliant messaging. We need workflow integration, rules based escalation of messages, and routing based on time of day/location/schedules/urgency/licensure. We need automated clinical documentation tools that record what each team member does and then requires a review/signoff by an accountable professional, not writing War and Peace from scratch until midnight (as is the current practice for many primary care clinicians)
3. (Value-based purchasing) Fee for service is dying and is being replaced by alternative quality contracts based on risk sharing.
Dr. Allan H. Goroll’s excellent New England Journal of Medicine article notes that EHR 1.0 has achieved exactly the result that historical regulation has required - a tool that supports billing and government reporting - not clinician and patient satisfaction.
Our electronic tools for EHR 2.0 should include the functionality necessary to document care plans, variation from those plans, and outcomes reported from patient generated healthcare data. Components of such software would include the elements that compromise the “Care Management Medical Record” - enrolling patients in protocols based on signs/symptoms/diagnosis, then using customer relationship management concepts to ensure patients receive the services recommended.
ICD-10, CPT, and HCPCS would no longer be necessary. Bills will no longer be generated. Payments would be fixed per patient per year and all care team members would be judged on wellness achieved for total medical expense incurred. SNOMED-CT would be the vocabulary used to record clinical observations for quality measurement.
4. (Usability) I do not fault EHR developers for the lack of usability in medical software. They were given thousands of pages of regulations then told to author new software, certify it, and deploy it in 18 months. I call this the “ask 9 women to have a baby in 1 month” concept, since Meaningful Use timeframes violated the “gestation period” for innovation. How can we achieve better usability in the future? My view is that EHRs are platforms (think iPhone) and legions of entrepreneurs creating add on functionality author the apps that run on that platform. Every week, I work with young people creating the next generation of highly usable clinical functionality that improves usability. They need to be empowered to get/put data from EHR platforms and emerging FHIR standards will help with that.
I was recently asked to define HIT innovation. I said it was the novel application of people, processes and technologies to improve quality, safety and efficiency. Creating modules that layer on top of existing EHR transactional systems embraces this definition.
5. (Consumer driven) In a recent keynote, I joked that my medical school training (30 years ago) in customer service mirrored that provided by the US domestic airlines. Healthcare experiences can be like boarding a crowded aircraft where your presence is considered an inconvenience to the staff. We’re entering a new era with evolving models that are moving care to the home including internet of things monitoring, supporting convenient ambulatory locations near you, offering urgent care clinics with long hours, enabling electronic self scheduling, and encouraging virtual visits. Although existing EHR 1.0 products have patient portals, they have not made the patient/family an equal member of the care team, providing them with care navigation tools. BIDMC is working on an Amazon Echo/Alexa service backed by microservices/Bots that brings ambient listening technologies to the home for coordination with care teams. When see you articles like this one, you know that the technology tools we have to support patients as consumers are not yet sufficient.
The US has been working on EHR 1.0 for a long time. 57 years ago, the New England Deaconess computerized its pharmacy using an IBM Mainframe. Here’s the original document from 1960 describing the achievement. Of note, the document highlights that the overall hospital budget reached a new high - $5.4 million and the increased salary, clinical care and IT expense meant that hospital rates would have to be raised to $25/bed/day. After nearly six decades of work on EHR 1.0, let’s declare victory and move onto social networking-like groupware supporting teams of caregivers focused on value while treating patients as customers using mobile and ambient listening tools. Government and private payers need to align incentives to support this future based on outcomes, putting the era of prescriptive EHR 1.0 functionality (and the energy enforcing the regulations) behind us.
Thursday, May 25, 2017
Building Unity Farm Sanctuary - 4th week of May 2017
Spring’s warmth and rain is accelerating our plant and mushroom growth such that every day is a balance between agricultural management and sanctuary development activities like trail building as pictured below. The stone bridge you see was built in the early 1800's.
The adventuresome project of last weekend was replacing the 20 year old heating oil tanks in the Sanctuary. The seams were weeping and oil was accumulating on the sides of the tanks. I recently heard a nightmarish story about an oil delivery of 500 gallons into a 250 gallon tank that had a newly ruptured seam. With new tanks, we’ve avoided that risk. The challenge is that the sanctuary has no basement - just a 4 foot crawl space. To extract the old oil tanks we had to remove the staircase in the crawl space and lift the tanks to the first floor without spilling old oil or scratching the wood floors. Not fun, but we were successful.
The other not fun project was replacing all the fiberglass insulation in the crawl space. In the past, the roof gutters directed water immediately down the side of the building and into the basement causing annual flooding and mold. We’ve redone the gutters to direct all water away from the foundation. The crawl space has stayed completely dry this spring. I pulled 200 linear feet of fiberglass insulation out from the crawlspace, bagging it to avoid dragging mold, mouse droppings and fiberglass through the building. Lying on my back in the dirt of the crawlspace, I reapplied rolls of R19 insulation and a vapor barrier. I wore goggles, a mask and full body loose fitting clothing, minimizing fiberglass misery.
While doing the fiberglass project I found a few more hundred feet of old wiring and rusted electrical boxes. At this point, the only wires in the entire crawlspace are active electrical lines, fire detection sensors, and internet fiber. Victory!
The next great archeological challenge will be replacing the entire water system and all the plumbing in the crawlspace. At the moment the plumbing is like the city of troy - built in layers. What needs to be done? I’ll take a sawzall at the input pipe from the well and at the main distribution for the building, removing everything in between - a maze of copper and valves installed 1959-1995. Much of our work on the sanctuary is not about adding infrastructure, it’s about removing 50+ years of infrastructure layers. The only water system that is needed is a simple pressure tank with a small debris filter directly connected to the house and paddocks. No water treatment, softeners, or iron removal are needed, massively reducing complexity. There’s no need for segregated filtered and unfiltered plumbing. The water test shows that the well is perfect - 10 gallons per minute of sterile, iron free water, so we’ll go from a deep underground stream to house and animals without anything in between.
As unexciting as it sounds, we’ll also be replacing the toilets which date from 1960 to 1990. In the early 1990s toilets went from high flow to low flow and the models from that era are incredibly unreliable. Given that the sanctuary is a public space, having a plunger in every room is not the right solution. Toto toilets will be in place by June.
In the mid 1990s a carriage house/workshop for storage and vehicles was built on the sanctuary property but it was never finished. There were live electrical wires hanging from the ceiling, walls were primed but never painted, and the fire/smoke alarms were disconnected. I’ve redone all the electrical/lighting, connected fully wired fire/smoke alarms to the main house by running cable through an underground conduit, and begun the process of wall/ceiling finish work. The carriage house will become our honey processing area and serve as one of our teaching areas for beekeeping, beer making, and mushroom cultivation. By July it should be finished to perfection.
This week, the stone dust necessary to finish the paddocks arrives. How much do we need? The paddocks are a trapezoid 300 feet on one side, 225 on the other side and 200 feet wide. If you remember your geometry, the area is (300+225)/2*200=52500 square feet. Just how much stone dust will cover 52,500 square feet at 3 inches thick (recommended for horses) - just go to this website and you’ll discover we need 700 tons i.e. 1.5 million pounds. The first 200 tons arrived yesterday.
Once the stone dust is placed, the fencing goes in and by mid June we’ll have four quarter acre paddocks for new rescues. As soon as its done, I’ll post pictures.
By the time the Summer gives way to Fall, the building of the sanctuary should be complete and my blog posts can return to the joys of running a farm and sanctuary, since maintaining is much easier than creating.
The adventuresome project of last weekend was replacing the 20 year old heating oil tanks in the Sanctuary. The seams were weeping and oil was accumulating on the sides of the tanks. I recently heard a nightmarish story about an oil delivery of 500 gallons into a 250 gallon tank that had a newly ruptured seam. With new tanks, we’ve avoided that risk. The challenge is that the sanctuary has no basement - just a 4 foot crawl space. To extract the old oil tanks we had to remove the staircase in the crawl space and lift the tanks to the first floor without spilling old oil or scratching the wood floors. Not fun, but we were successful.
The other not fun project was replacing all the fiberglass insulation in the crawl space. In the past, the roof gutters directed water immediately down the side of the building and into the basement causing annual flooding and mold. We’ve redone the gutters to direct all water away from the foundation. The crawl space has stayed completely dry this spring. I pulled 200 linear feet of fiberglass insulation out from the crawlspace, bagging it to avoid dragging mold, mouse droppings and fiberglass through the building. Lying on my back in the dirt of the crawlspace, I reapplied rolls of R19 insulation and a vapor barrier. I wore goggles, a mask and full body loose fitting clothing, minimizing fiberglass misery.
While doing the fiberglass project I found a few more hundred feet of old wiring and rusted electrical boxes. At this point, the only wires in the entire crawlspace are active electrical lines, fire detection sensors, and internet fiber. Victory!
The next great archeological challenge will be replacing the entire water system and all the plumbing in the crawlspace. At the moment the plumbing is like the city of troy - built in layers. What needs to be done? I’ll take a sawzall at the input pipe from the well and at the main distribution for the building, removing everything in between - a maze of copper and valves installed 1959-1995. Much of our work on the sanctuary is not about adding infrastructure, it’s about removing 50+ years of infrastructure layers. The only water system that is needed is a simple pressure tank with a small debris filter directly connected to the house and paddocks. No water treatment, softeners, or iron removal are needed, massively reducing complexity. There’s no need for segregated filtered and unfiltered plumbing. The water test shows that the well is perfect - 10 gallons per minute of sterile, iron free water, so we’ll go from a deep underground stream to house and animals without anything in between.
As unexciting as it sounds, we’ll also be replacing the toilets which date from 1960 to 1990. In the early 1990s toilets went from high flow to low flow and the models from that era are incredibly unreliable. Given that the sanctuary is a public space, having a plunger in every room is not the right solution. Toto toilets will be in place by June.
In the mid 1990s a carriage house/workshop for storage and vehicles was built on the sanctuary property but it was never finished. There were live electrical wires hanging from the ceiling, walls were primed but never painted, and the fire/smoke alarms were disconnected. I’ve redone all the electrical/lighting, connected fully wired fire/smoke alarms to the main house by running cable through an underground conduit, and begun the process of wall/ceiling finish work. The carriage house will become our honey processing area and serve as one of our teaching areas for beekeeping, beer making, and mushroom cultivation. By July it should be finished to perfection.
This week, the stone dust necessary to finish the paddocks arrives. How much do we need? The paddocks are a trapezoid 300 feet on one side, 225 on the other side and 200 feet wide. If you remember your geometry, the area is (300+225)/2*200=52500 square feet. Just how much stone dust will cover 52,500 square feet at 3 inches thick (recommended for horses) - just go to this website and you’ll discover we need 700 tons i.e. 1.5 million pounds. The first 200 tons arrived yesterday.
Once the stone dust is placed, the fencing goes in and by mid June we’ll have four quarter acre paddocks for new rescues. As soon as its done, I’ll post pictures.
By the time the Summer gives way to Fall, the building of the sanctuary should be complete and my blog posts can return to the joys of running a farm and sanctuary, since maintaining is much easier than creating.
Thursday, May 18, 2017
Building Unity Farm Sanctuary - Third Week of May 2017
In case it seems that my posting frequency has dropped, it’s a combination of a hectic spring farming/sanctuary schedule and writing requests from outside organizations. For my views on the recent cybersecurity/ransomware events see the PBS Newshour blog.
Unity Farm Sanctuary work clothes have arrived in our closets. This was my wife’s idea to identify mentors and experienced volunteers on the property. We have so many visitors every day who are walking the trails, visiting the animals, and offering to help that we need to separate those with experience from those who are new to the sanctuary. The shirts make it easy to find someone knowledgeable.
Our 501(c)(3) charitable designation should be approved soon, but in the meantime, we're receiving donations of equipment and items considered useful for the sanctuary. For example, this 1800’s wheelbarrow seemed just the right tool for an 1833 meeting house. It was dropped off earlier this week. Some has just donated a canoe for sanctuary visitors who want to explore the upper marshes of the Charles River which has a canoe put in a few minutes drive from the sanctuary.
Later this week, another Welsh Pony, named Grace will arrive at the Sanctuary. We’re building new paddocks as fast as we can but they will not be ready until the end of June/early July. Grace will live with the goats in the short term. The goat paddock has two run ins so the pony can have a private space.
The process of creating 2 acres of new paddocks that are safe for horses takes diligence. First, we cleared brush and leveled out the land. Then we applied a layer of “tailings” rocks and dirt that provide a layer of drainage. Then “stone dust” provides the finished surface which is solid and smooth but still promotes drainage. Once that is done, we’re adding some additional fencing and gates so that we can easily bring in food and remove manure. Then we add south-facing run in buildings to protect the animals from inclement weather. Finally, we trench for electrical and water supplies to each building. I’ll be doing all the electrical and plumbing, so we keep expenses to a minimum. When completed, the 4 new paddocks, each about a half acre, will enable us to take on a few more creatures that need rescuing such as a donkey and a few sheep that we were recently told need a new home. We’re very careful to take on new animal responsibilities selectively so that we can provide each the daily attention it needs. As I’ve said before, we provide “forever homes” and thus we need to budget our time and resources for the long term support of any animal that arrives.
Next week, a “rafter” of turkeys arrives at the sanctuary, which will provide an instant family for Palmer, our Royal Palm tom turkey. Palmer is extremely social and follows humans on long walks into the woods. It will be fascinating to see how he adapts to young poults. Thus far, the 20 wild turkeys at the sanctuary do not interact much with Palmer, although they call to each other in the night.
The work on the sanctuary buildings continue and last weekend I removed all the obsolete electrical circuitry from the 1960’s. The 1833 Sanctuary building was moved to its current site in 1959 and the area underneath is only 3 feet high because of all the unmovable ledge rocks at the site that prevented digging a full basement. I found numerous open electrical boxes with exposed wiring in the crawlspace that looked a bit dangerous for anyone doing work on heaters, plumbing or other under building infrastructure. I carefully traced every wire and found that they were unconnected at both ends - just hundreds of feet of old cable and numerous electrical boxes with no purpose whatsoever. I removed everything. The good news is that neither the building’s electrical system nor my body was harmed in the process, although I did emerge from the crawlspace covered with mud, cobwebs, and decades of accumulated dust. I also removed old thermostat wires, door bell wires, and phone lines that have not been used in decades. I’m fairly confident that the work I’ve done thus far under the building - removing about half a mile of old wiring - is now done. Maybe I’ll never have to spend another weekend day crawling under the building. Luckily Claustrophobia and Arachnophobia are not issues for me.
This weekend will include the usual extra time with the animals, providing them companionship and extra exercise plus the tasks of spring - mushroom inoculation, planting warm weather seedlings (cucumbers/peppers/tomatoes). All of the apple trees are in bloom, all of the hoop house vegetables are thriving, and the mushroom logs are fruiting. 2017 should be a bumper crop.
Unity Farm Sanctuary work clothes have arrived in our closets. This was my wife’s idea to identify mentors and experienced volunteers on the property. We have so many visitors every day who are walking the trails, visiting the animals, and offering to help that we need to separate those with experience from those who are new to the sanctuary. The shirts make it easy to find someone knowledgeable.
Our 501(c)(3) charitable designation should be approved soon, but in the meantime, we're receiving donations of equipment and items considered useful for the sanctuary. For example, this 1800’s wheelbarrow seemed just the right tool for an 1833 meeting house. It was dropped off earlier this week. Some has just donated a canoe for sanctuary visitors who want to explore the upper marshes of the Charles River which has a canoe put in a few minutes drive from the sanctuary.
Later this week, another Welsh Pony, named Grace will arrive at the Sanctuary. We’re building new paddocks as fast as we can but they will not be ready until the end of June/early July. Grace will live with the goats in the short term. The goat paddock has two run ins so the pony can have a private space.
The process of creating 2 acres of new paddocks that are safe for horses takes diligence. First, we cleared brush and leveled out the land. Then we applied a layer of “tailings” rocks and dirt that provide a layer of drainage. Then “stone dust” provides the finished surface which is solid and smooth but still promotes drainage. Once that is done, we’re adding some additional fencing and gates so that we can easily bring in food and remove manure. Then we add south-facing run in buildings to protect the animals from inclement weather. Finally, we trench for electrical and water supplies to each building. I’ll be doing all the electrical and plumbing, so we keep expenses to a minimum. When completed, the 4 new paddocks, each about a half acre, will enable us to take on a few more creatures that need rescuing such as a donkey and a few sheep that we were recently told need a new home. We’re very careful to take on new animal responsibilities selectively so that we can provide each the daily attention it needs. As I’ve said before, we provide “forever homes” and thus we need to budget our time and resources for the long term support of any animal that arrives.
Next week, a “rafter” of turkeys arrives at the sanctuary, which will provide an instant family for Palmer, our Royal Palm tom turkey. Palmer is extremely social and follows humans on long walks into the woods. It will be fascinating to see how he adapts to young poults. Thus far, the 20 wild turkeys at the sanctuary do not interact much with Palmer, although they call to each other in the night.
The work on the sanctuary buildings continue and last weekend I removed all the obsolete electrical circuitry from the 1960’s. The 1833 Sanctuary building was moved to its current site in 1959 and the area underneath is only 3 feet high because of all the unmovable ledge rocks at the site that prevented digging a full basement. I found numerous open electrical boxes with exposed wiring in the crawlspace that looked a bit dangerous for anyone doing work on heaters, plumbing or other under building infrastructure. I carefully traced every wire and found that they were unconnected at both ends - just hundreds of feet of old cable and numerous electrical boxes with no purpose whatsoever. I removed everything. The good news is that neither the building’s electrical system nor my body was harmed in the process, although I did emerge from the crawlspace covered with mud, cobwebs, and decades of accumulated dust. I also removed old thermostat wires, door bell wires, and phone lines that have not been used in decades. I’m fairly confident that the work I’ve done thus far under the building - removing about half a mile of old wiring - is now done. Maybe I’ll never have to spend another weekend day crawling under the building. Luckily Claustrophobia and Arachnophobia are not issues for me.
This weekend will include the usual extra time with the animals, providing them companionship and extra exercise plus the tasks of spring - mushroom inoculation, planting warm weather seedlings (cucumbers/peppers/tomatoes). All of the apple trees are in bloom, all of the hoop house vegetables are thriving, and the mushroom logs are fruiting. 2017 should be a bumper crop.
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