Unity Farm Sanctuary – A Community Benefit Startup

Recently I was speaking to Nick Dougherty, managing director of MassChallenge HealthTech, the digital health accelerator in Massachusetts. After analyzing hundreds of startups, he concluded there are three types of companies:

1. Transactional – Buy my product.  If you don't like it, I'll try someone else.
2.  Confirmatory – Do you like my product?  If you don't like it, I'll change it for you.
3.  Diagnostic – What product do you need to solve your most pressing issues?

Transactional companies limp along. Confirmatory companies succeed but not wildly. Diagnostic companies can grow exponentially.

Unity Farm Sanctuary in Sherborn, Mass., was started by my family in late 2016 as a non-profit providing a safe and loving lifelong home for farm animals.

Our sense was that such services were an unmet need in Massachusetts, where few organizations serve as sanctuaries and most are at capacity. Although we had experience raising dogs and caring for small animals, as well education in farm operations from the University of Massachusetts, every day has been a learning opportunity. We had to master large animal handling, medical care and four-season food/water supplies.

The first two years were very transactional and confirmatory with the public. We had a vision and modified that vision as we learned. As an engineer and clinician, I focused on the facilities and animal care, maturing the processes of daily operation. My wife, educated in the humanities and arts, is a people person. She immersed herself in the daily hours of training and educating every new volunteer and visitor.

With time, however, we discovered that running Unity Farm Sanctuary required a diagnostic approach. We learned that the public really wanted a place that promoted a culture of kindness and connection.

What do I mean?

In a world of too much stimulation – streaming videos, a 24x7 news cycle and high-paced video games –  there needs to be a place where you can step away from the anxiety and spend an hour grooming a goat. Or giving a 2500 pound bull a back scratch. Or feeding the chickens. Walking a woodland trail for quiet reflection is a powerful tonic. Watching alpaca pronk (bounce around) at sunset puts life into perspective.

Especially in a time of COVID and political polarization, there is a need for human-animal bonding. These interactions are diverse and spontaneous. In the days following the 2020 Presidential election, we had Boston-area visitors arrive to sit with the goats and just enjoy their company.

When we first started the sanctuary, the volunteer program was small and unstructured. Today we have 350 volunteers that earn specific credentials/badges for their knowledge and experience.

We serve volunteers and visitors with handicaps of all kinds. Some may not relate to other people, but they can easily relate to a horse. Some people develop a bond with a particular animal, and some people bond to the whole environment of the forest and paddocks. We have story after story of people from one to one hundred years old finding their bliss while serving rescued animals.

I've not found the term "community benefit startup" in common use, but that is what Unity Farm Sanctuary has become. The structure is a 501c (3) charity on 30 acres of owned land designated as a town forest/trail, and surrounded by other protected space, creating a 70 acre plateau with no immediate neighbors. There are 4 miles of trails, 5 streams, 2 ponds and 3 tree houses.  

The transformation in thinking that surprised me the most was that our service to volunteers is as important as our service to animals.  Updates about the health and activities of each rescue bring a bright spot to the day of the volunteers who give their time, energy and contributions to sustain the small city that Unity Farm Sanctuary has become. Feeds on Facebook, Instagram, Twitter, Tumblr and Pinterest require daily diligence, but the community benefit of posting them is palpable.  

At Mayo Clinic where I serve as President of Mayo Clinic Platform, we believe that innovation happens when you start small, think big, and move fast https://www.amazon.com/Think-Start-Small-Move-Fast/dp/007183866X. Unity Farm Sanctuary is a perfect example of that idea. It started with a few chickens and now, three years later, is one of the largest animal sanctuaries in New England.  Being agile enough to listen to the needs of hundreds of stakeholders led us to create a community benefit startup. I firmly believe that a new class of organization, creating positive emotional, physical and mental experiences for volunteers, will be increasingly important in a world that needs more empathy and compassion. Unity Farm Sanctuary, a community benefit startup, is an early example.

Network medicine offers new insights into susceptibility to diseases such as COVID-19

In the past year, we've become familiar with the factors that can make a person more vulnerable to COVID-19 infection. The elderly are more at risk, as are those who smoke and are already dealing with other diseases, such as cancer and Type 2 diabetes.

At a deeper level, though, there are dozens of other factors that may come into play and influence a person's susceptibility to disease. A recent analysis of hospitalized COVID-19 patients in 14 states found that among patients ages 50-64 that obesity was the most prevalent underlying medical condition. Similarly, there's growing evidence to suggest that vitamin D deficiency contributes to COVID-19 infection.

The emerging field of network medicine, powered by this type of digital analysis of large data sets, sheds light on the interplay between microbial virulence and the ability of a person's immune system to defend against diseases such as COVID-19. Network medicine allows researchers and physicians to look beyond the traditional root causes of disease and take a more holistic approach to identify agents that can influence a person's susceptibility to disease.

In an article that I co-authored with Paul Cerrato and Adam Perlman, M.D., MPH, for Mayo Clinic Proceedings: Innovations, Quality and Outcomes, we describe how the analytic power of supercomputers and the emergence of big data sets has given researchers new insights into the causal relationships that influence susceptibility to disease. This technology dramatically improves our ability to assess the relative strengths and weaknesses of factors as contributing agents.

Some of these agents are not surprising — nutritional status, for one, and environmental factors. Others may be harder to assess, like sleep habits, exercise, physical and psychosocial stressors, obesity, protein-calorie malnutrition and emotional resilience. Genetic variations such as single-nucleotide polymorphisms also are examined as possible agents affecting a person's vulnerability to disease.

With possible factors identified, deep learning algorithms can assess each's likely strengths and weaknesses as contributing factors to disease and help identify therapeutic options.

Using machine learning-enhanced algorithms to analyze risk factors and their interactions can help determine which ones can predict a person's risk of COVID-19 infection or the prognosis for someone who already has tested positive.

At a time when we're all looking for reasons for hope and encouragement — and the national rollout of a COVID-19 vaccine is a big one — it's good to remember that our capabilities to gain essential insights from AI, network medicine and deep learning algorithms are ever-growing and that we have the potential not only to resolve this pandemic more quickly but to completely redesign how we respond to pandemics in the future.

The Facilitation of Change in Health Care

Recently, the Washington Post gave an in-depth analysis from the frontlines of the pandemic in Eau Claire, Wis. The moving piece portrays the compassion and ingenuity needed from frontline providers to meet patient needs during a COVID-19 surge. It is a portrayal of excellence that reminds me why so many pursue work in health care. 

The article highlights the deployment of a hospital-at-home model to increase hospital capacity for the surge. Rita Huebner’s experience in Mayo Clinic’s advanced care at home offering provides a great exemplar of how technology facilitates patient-focused change within the health care system.  

Recently, Paul Cerrato and I published “The Digital Reconstruction of Health Care,” where we explored the digital transformation in health care that will facilitate care delivery change. Artificial intelligence and remote monitoring enable new knowledge generation, cost efficiencies and expand the care continuum. Our analysis examines the transition from brick-and-mortar to online care, providing a rationale for the shift. 

Many industries have undergone digital transformation. Nine years ago, Uber launched an app and ride-sharing service that focused on connecting users seamlessly to the ubiquitous “black” cars prevalent in the major cities. This service's facilitation through Uber’s platform grew in popularity, expanding to ordinary cars and flipping the taxicab industry on its head.

Health care is experiencing a similar digital renaissance that will change how some elements of care are delivered. COVID-19 has accelerated the adoption of telemedicine, hospital-at-home and remote patient monitoring. The capabilities offer valuable methods for scaling the health care system, achieving cost efficiencies, and expanding the care continuum. However, as we see in Wisconsin, people will remain at the heart of the strategies and care.

COVID-19 Update Part II: Collaborations & Insights to Come

Over the past seven months, COVID-19 has impacted our lives, and my writing moved from social media to Mayo internal communications, pandemic response research papers, and COVID-focused public awareness campaigns. While the challenges have been considerable, the work since April has validated that the health care system needs novel technologies, policy reform and cultural change.  It's time to return to social media posting.

COVID-19 has forced a level of focus and collaboration that is accelerating the Mayo Clinic Platform's formation. While we are still navigating the pandemic challenges, but despite the obstacles, there has been significant work accomplished on the platform and through external organizations.

The COVID-19 Healthcare Coalition and The Fight is in Us are two organizations that have emerged, and I have engaged with them to address pandemic needs. Both represent examples of how private and public-private collaborations leverage individual strengths to accomplished shared goals. It is this spirit of cooperation that platform business enables what we are creating with the Mayo Clinic Platform.

While 2020 derailed many business plans, the Mayo Clinic Platform has maintained its focus and implementation schedule. The focus, dedication and teamwork have been extraordinary. The first two business lines, the Clinical Data Analytics Platform and the Virtual Care Platform, were launched and operationalized. A third business line, the Remote Diagnostics and Management Platform, is in development with promising projects.

I look forward to chronicling this journey for you with weekly posts to this blog and additional insights on LinkedIn and Twitter.

Reinventing Clinical Decision Support

In our latest book, Reinventing Clinical Decision Support: Data Analytics, Artificial Intelligence, and Diagnostic Reasoning, Paul Cerrato and I explore the promise of artificial intelligence and machine learning for improving clinicians’ ability to make more informed diagnostic and therapeutic decisions. Here’s an excerpt from Chapter 2:

“AI is a once-in-a-generation transformative technology. As such, expect its impact to be on the scale of the advent of electricity or the Internet,” says Jean-Claude Saghbini, Wolters Kluwer Health.(1)

“Artificial intelligence and machine learning are set to transform healthcare. From front line care delivery, including triage, clinical decision support and patient experience to back office operations, such as billing and revenue cycle, algorithms and emerging technologies are already proving their value,” according to a recent report from Healthcare Information Management Services Society (HIMSS). (1)

Both enthusiastic visions suggest that artificial intelligence (AI) and machine learning (ML) are poised to transform medicine and bring in an era of cost effective patient care. But these predictions have to be weighed against less optimistic views, including those that suggest AI will disrupt the workforce in healthcare and other industries, causing many to lose their jobs to soulless

algorithms and robots.

Israeli historian Yuval Noah Harari, for example, believes that: “For now, most of the skills that demand a combination between the cognitive and manual are beyond AI’s reach. Take medicine . . . ; if you compare a doctor with a nurse, it’s easier for AI to replace a doctor—who basically just analyzes data for diagnoses and suggests treatments. But replacing a nurse, who injects medications and bandages, is far more difficult. But this will change; we are really at the beginning of AI’s full potential.” (2)

There are futurists who are far more optimistic, however. They imagine a scenario in which every patient gets the same quality of care afforded presidents in affluent countries or billionaire CEOs at major technology companies. With the assistance of AI, machine learning, and massive databases, they envision a world in which we each have the electronic equivalent of a personal physician who has access to the very latest research, the best medical facilities that specialize in each individual’s health problems, access to cutting-edge data sets, predictive analytics, testing options, clinical trials currently enrolling new patients, and much more. For example, Alvin Rajkomar, MD; Jeffrey Dean, MD, of Google; and Isaac Kohane, MD, PhD, of Harvard Medical School, describe a possible future in which:

A 49-year-old patient takes a picture of a rash on his shoulder with a smartphone app that recommends an immediate appointment with a dermatologist. His insurance company automatically approves the direct referral, and the app schedules an appointment with an experienced nearby dermatologist in 2 days. This appointment is automatically cross-checked with the patient’s personal calendar. The dermatologist performs a biopsy of the lesion, and a pathologist reviews the computer-assisted diagnosis of stage I melanoma, which is then excised by the dermatologist.(3)

This scenario stands in stark contrast to the current state of affairs that often transpires in today’s broken healthcare ecosystem. As Rajkomar et al.3 point out, in today’s ecosystem, this patient is more likely to ignore his skin lesion for far too long; his primary care physician may misdiagnose the melanoma because of its atypical appearance, and the delay may result in a metastatic malignancy that requires systemic chemotherapy.

With such contrasting views, clinicians have to wonder: What precisely will the future look like? Our purpose in Chapter 2 is to explore the strengths and weaknesses of AI and ML and to help clinicians and technologists gain a realistic view of the near future—a future that promises to deliver more cost effective, more personalized care but also one that faces numerous challenges. We will explore basic terminology and concepts and discuss AI/Ml solutions in

a variety of medical specialties. In Chapter 3, we will outline the many challenges that stand in the way of the full implementation of these solutions. 

More details from Chapter 2 will appear in a subsequent blog. A full discussion of AI/ML is available in our book.

References

1. “AI and Machine Learning: What Cuts Hype from Reality.” Healthcare IT News. Retrieved on April 8, 2019.

2. Kaufman D. (2018, October 19). “Workers Beware: Algorithms Could Replace You—Someday.” The New York Times, p. F2.

3. Rajkomar, A., Dean, J., and Kohane, I. (2019). “Machine Learning in Medicine.” New England Journal of Medicine, vol. 380, pp. 1347–1354.

A COVID update

I realize that my blog post frequency has diminished during COVID.   Writing time has been redirected to the national COVID-19 coalition and its 14 workgroups:

Analytics
Modeling & Simulation
Health Systems and Clinical SME
Supply Chain
Telehealth
Testing
ICU and Mechanical Ventilation
COVID-19 Data Standardization (mCoVD = Minimal COVID-19 Viable Dataset)
Non-Pharmaceutical Interventions
Optimization of Clinical Therapeutics/Protocols
Data Storage and Source
Dis/Misinformation
Privacy Advisory
Contact Tracing

Below is a description of this week's highlights

a. Critical Shortages of Personal Protective Equipment (PPE)

Worked with international suppliers to deliver 580,000 FDA-certified respirators to New York City hospitals, working through Governor Cuomo’s procurement office.

Connected 100,000 FDA-certified respirators to Masks for America, a volunteer coalition of everyday Americans joining forces to deliver protective masks directly to frontline healthcare workers in COVID-19 hotspots.

Prepared guidelines, assisted purchases, and piloted novel solutions to decontaminate respirators so they can be reused multiple times, extending their lifecycle.

b. Implementing Social Policies

Launched a Non-Pharmaceutical Intervention  (NPI) dashboard that provides real-time tracking of state-wide NPI implementation.  As States begin relaxing NPIs, we’ll be able to see the impact. 

c. Achieving Data-Driven Clinical Care Outcomes

Coalition members, including numerous electronic health record vendors, are developing a minimal common data set for COVID-19.  This is now being used to research the outcomes of clinical outcomes on treatments, such as hydroxychloroquine, Remdesivir, and others.   We have designed a federated query approach so that any institution can participate in studies by running queries locally in their EHR. 

Supporting the rapid scale-up of telemedicine as part of a fully integrated healthcare delivery system.  With Mayo's help we are running multiple studies about the adoption of telemedicine during COVID.   See a starting set of best practices in the Resource Library

Detecting Dis/misinformation Related to COVID-19.   Dis/misinformation or outright fraud can affect patients' ability to understand and adhere to non-pharmaceutical interventions and, most importantly, their health.  A new dashboard will be published soon.

Supporting the Mayo Clinic-led national convalescent plasma trial, which is attracting thousands of health systems and patients.  We have worked closely with EHR vendors to develop order sets and a data analysis approach.

Supporting the Contact Tracing activities of Apple, Google, MIT and others with connections to the Association of State and Territory Health Officers, Bluetooth experts at Lincoln Labs, and leveraging an Amber alert like technology called Sara alert for infected patient followup. 

d. International Regulatory Standards and Comparison for N95 Respirators

Due to the shortage of N95 respirators in the U.S. during the pandemic, organizations are ordering similar respirators from international companies. We’ve listed what’s available from 7 countries and which products are FDA-authorized.  

e. Ventilator Training App

This multi-vendor library of training and product materials for medical professionals was created through a partnership of leading ventilator manufacturers and Allego, Inc. You’ll find free mobile access to video overviews, instruction manuals, and other training materials for equipment that is critical to treating patients suffering from COVID-19-related respiratory distress.   See

f. Coronavirus Scientific Literature Topic Browser

Researchers looking for COVID-19-related articles of clinical or scientific interest should try this interactive tool. The COVID-19 Open Research Dataset (CORD-19) is presented in several views, allowing users to quickly find clusters of papers on a desired topic. 

Coming Together to Save Lives

The following is a post from the members of the COVID-19 Healthcare Coalition ,  #C19Coalition co-chaired by  Dr. Jay Schnitzer, Chief Medical and Technology Officer at MITRE  @MITREcorp who directs initiatives in health/life sciences and Dr. John Halamka @jhalamka, President of Mayo Clinic Platform who leads a portfolio of platform businesses focused on transforming health.
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Pandemics thrive in confusion.

Not because diseases like COVID-19 have intent, but because the lack of a focused response makes the spread of disease so much easier.

Pandemics stress our healthcare delivery system. We are now familiar with the generalized public health measures that help contain the spread of infectious disease including social distancing, hand washing, self-quarantine, cancellation of large public events, and school closures.    More targeted measures are needed and that requires coordination.

We need to leverage the strengths of the private sector. By bringing together healthcare organizations, technology companies, non-profits, academia, and startups we can leverage their unique strengths  for the benefit of all.

Over the past week, we've launched the Covid-19 Healthcare Coalition involving Amazon Web Services, Arcadia Health, athenahealth, Buoy Health, the CommonWell Health Alliance, HCA Healthcare, Intermountain Healthcare, LabCorp, Leavitt Partners, MassChallenge, Mayo Clinic, Microsoft, MITRE, Rush University System for Health, Salesforce, University of California Healthcare System and many others.

We've already begun focused efforts to increase COVID-19 testing capacity for the country, to coordinate early therapies, and to accelerate vaccine development.

We established guiding principles for the coalition:

1. Everyone participates for the benefit of those impacted by COVID-19

2. Everyone cooperates and openly seeks to assist each other when possible

3. Nobody will get paid. Bring your resources and no money will be exchanged

4. Verbal agreements will suffice to get us started

5. If you agree to these terms and conditions, you’re in

Our first task is to share learnings and encourage innovation across the coalition.

We’re moving fast to support technology and policy innovations.   MITRE, a national research and development center, is serving as program manager.

Pandemics thrive in confusion and wither against a united, clear-eyed attack.

Let’s shut down COVID-19 together.

Unity Farm Sanctuary and COVID Planning

You might think a farm sanctuary doesn't need cyber-liability insurance (we do because we track social security numbers associated with donations).  You may not think that a Farm Sanctuary needs a comprehensive COVID plan.

We need a plan for five reasons
1.  We are a community gathering point for over 100 volunteers and hundreds of people taking enrichment classes including Yoga, Tai Chi, Meditation, Beekeeping, and Council on Aging activities.
2.  We are an employer with full time and part time workers
3.  We are accountable for the health of more than 250 creatures.   Without humans, these creatures would lack daily care
4.   As the economic impact of job losses reduces the ability of the community to support its animals, sanctuary services become increasingly important
5.   The community is looking to us for guidance

So what did we do?    Weeks ago, we realized that aggressive measures were needed.   We closed the farm sanctuary to the public.   We paused all classes.    We put the volunteer program on hold.    We began an aggressive disinfection/biological isolation protocol. 

At this point, only my wife and I plus 3 key employees come to the property.   Here is the email we sent to the community a few weeks ago

"My valued friends,
Effective immediately, Unity Farm Sanctuary is limiting access to the Sanctuary

Here's important background information
https://opensanctuary.org/article/how-should-sanctuaries-respond-to-covid-19/.

Currently, the vast majority of sanctuaries surveyed (on the two international sanctuary groups I belong to) have eliminated all volunteers and only have the smallest number of staff possible to run their sanctuaries. They all state that the owners and the core staff must stay as healthy as possible and limit their exposure. Most of us who run sanctuaries are most concerned too about feed supply-chain. Core staff will be focused on this this week.

If our core staff is sick, we will be in a VERY difficult place. (I am actually in a higher risk group from my own immune system - I am a breast cancer survivor, I have Graves Disease, I have had pneumonia in the past, I am very vulnerable to upper respiratory virus as a general rule, and I am nearing 60.)

Starting Monday, no volunteers will be onsite, no visitors, no tours, no classes. Staff will be pared down to the smallest group of core people we can manage. This will hold at minimum to April 6, and based on what I know from our connections through John's connections to experts, in our country you can expect at least an 8 week timeframe on groups, gatherings and interpersonal contact limits.

Please take social distancing seriously. I am restricting volunteers here so that I keep you healthy too. I want to hear that every single one of you is doing well and safe. I will be posting on newsletters, Instagram and FB as much as possible so that people do not feel disconnected.

Sincerely,
Kathy Halamka"


And here is what we communicated to the staff

"Staff that is remaining on schedule will be following these precautions:
-All plastic and metal surfaces outside the house will be wiped down at noon and 7pm with bleach wipes.  Inside the Unity Meeting House we will focus on kitchen, bathroom, laundry room, and tables (handles, knobs, hayboxes, steering wheels,,,,)
-Staff should have no reason to go upstairs, so please stay on the first floor of the house so we do not need to wipedown the entire 2nd and 3rd floor as well.
-Wash hands thoroughly throughout your shift (and at home!)
-Keep distance between staff members (per CDC recommendations)
-If you or a family member are not feeling well or you believe you have come in contact with someone with COVID-19, stay home and self quarantine! (Let me know asap so we can find coverage)

In addition, we have been working hard to stock up on supplies (hay, grain, cleaning supplies)

Remember this is all temporary, and an effort to keep everyone healthy and safe so we can continue to care for our animal residents. If anyone has any questions please feel free to email, text, or call. "

The COVID pandemic will be filled with stories of amazing leadership and inspiration.    This once in century event effects all of us, even the citizens of Unity Farm Sanctuary.    We're doing our best to ensure every creature is comforted as we shelter in place.

Bringing Out the Best in Us

In the upcoming week you'll see numerous writings about national private sector efforts to enhance COVID response, communication, and collaboration.

As part of doing this work, one of my colleagues noted that the she's seen many recent examples of current events bringing out the best in people.     There's a willingness to help, a eagerness to volunteer, and a sense of belonging by banding together for a common cause.    Yes there are stories about hoarding toilet paper and purell, but those are minor distractions compared to the good things happening around us.

Here are examples of what I've seen in the past 24 hours.

1.  A major data analytics company focused on COVID modeling asked to collaborate with a major vaccine lab to accelerate development

2.  A group of competing companies aligned to create national policy requests that enable more virtual care

3.  Two competing big tech companies agreed to work together on helpful web-based resources for the country

4.  Big tech companies are offering expertise and credits for cloud resources

5.  An EHR company is working on a heat map showing orders placed for COVID testing as a proxy for virus spread

6.  An AI company is creating a map of national searches for COVID symptoms as a proxy for virus spread

7.  Many companies are offering free/reduced cost services in support of COVID response

8.  A non-profit recognized that we'll likely need a national vaccine registry linked by a nationwide patient matching strategy when a vaccine is available 12-18 months from now.    They will assemble a guiding coalition for that effort.

9.  A group of investigators is working on a trial of using convalescent plasma as a mechanism of conferring immunity. 

10.  A laboratory is seeking coronavirus positive blood to accelerate the development an easy to run, highly specific serology-based blood test

For all the anxiety we feel, it's clear that many people are working for the common good.    So if you're feeling that the future will be more Mad Max than Star Trek, realize that people around the world are working together to create the best possible outcome.

Working together, we can make a difference.

What's a Platform Go Live?

As we plan our go-lives for the Mayo Clinic Platform, we recently discussed how best to measure what constitutes a go-live.

First, let's review what Platform thinking (technology, policy, people and process) can do for an organization.

*Facilitates collaborations and partnerships with external entities (i.e. participants on the Platform benefit from the presence of other participants)
*Connects assets (data, algorithms, expertise) with customers in ethical, privacy protecting ways
*Supports the development of ideas into products that may be licensed, spun out, or sold as services
*Has turnkey technology and policy approaches that empower innovators to incubate/accelerate their ideas with agility, such as assistance with validation/FDA clearance assessment or other common regulatory hurdles

Success can be measured in many ways - impact on patient care, the boldness of the innovation, value creation for all participants, public perception of the work, and time to market.  Value creation could be licensing, transactional revenue, or equity growth.

Different audiences may have different perceptions of go-lives.    While it would be tempting to conflate general availability (GA) of our Platform offerings with go-live, we believe that the Platform won't be live until an "active customer" or stakeholder actually uses what we have to offer.

With these ideas in mind, here are few straw definitions for the concept of go-live for the Mayo Platform businesses.

 1.  The Clinic Data Analytics Platform (CDAP) accelerates new insight discovery by enabling analysis of de-identified historical data stored within a secure cloud hosted container controlled by Mayo Clinic.     A reasonable definition of go live is that CDAP data and tools become available such that a customer runs a data analysis that yields new insights for that customer, for example discovering a potential path forward for COVID-19 care or treatment (the "active customer" criterion)

2.  The Home Hospital Platform enables high acuity care via telemetry, clinical care coordination, communication, supply chain, and record keeping.   A go-live occurs when a home hospital discharge occurs with a patient restored to health after management facilitated by Platform components hosted on Mayo Clinic Cloud.  (the "active patient" criterion)

3.  The Remote Diagnostic and Management Platform accepts a signal/data via a Mayo hosted orchestration engine, sends it to an algorithm/interpretation service, and a high quality diagnosis/interpretative result is returned to a customer, for which a payment is generated (the "active orchestration" criterion)

4.  We're thinking of developing some supportive functions such as FDA clearance services.  An approved FDA clearance would constitute a go live (the "demonstrated expertise" criterion).     The reason we are considering a standard function for FDA clearance as part of acceleration/incubation services is because of the significant complexity and expense of  FDA clearance:

a.       Regulatory Pathway Determination: $21-23K.  Takes about 2 months to complete
b.       Gap Analysis & QMS Implementation: $220K (800 hrs.) - $495K (1,800 hrs.), depending on results of Gap Analysis (how much needs to be done)
c.       FDA Pre-submission prep & meetings: $98K (354 hrs.)
d.       Complete FDA submission and clearance: $275-400K (1,000-1,200 hrs.)

A service that can pool experience, talent and technology to get synergies and scale to lower the unit cost and speed of FDA clearances would be a win for everyone.

5.   As we create our staffing model, we'll have functions that cross all new Platform businesses and dedicated roles in each business.   For example, across all businesses we'll have one team overseeing the communication plan and one team processing new business ideas/collaboration requests.     If a new proposal can be reviewed, analyzed, a go/no go decision made, and a new business launched, that would constitute a go-live of the function being open for business.    (the "process maturity" criterion)

In 2020, we're aiming for at least one go-live per quarter, celebrating the "ribbon cutting" of objectively measured Platform progress.   Next quarter, we'll launch the CDAP tool for Mayo internal users and begin processing our first queries for external customers.

To me, our most "pure Platform" go-live will be when we have a generalizable model for ingesting data, interpreting it with novel analytics/algorithms/services and returning a result within the workflow of the customer.    It's also one of the most challenging to assemble.    I'll be writing about our journey for that go-live throughout 2020.

What is the Architecture of a Modern Platform?

Platform businesses require technology that promotes interoperability and scalability.  For those who live in platform companies day-to-day, my thinking below may sound obvious, but for those who are thinking about a cloud journey, the list of technologies below may be helpful.

Storage and compute functionality in the cloud enables agility via "infrastructure as code" products such as Terraform.    Terraform enables virtual server spin up on demand within applications to provision and manage any cloud, infrastructure, or service.   Each cloud provider has strengths.    Customers like Google Cloud Platform because of BigQuery, which scales infinitely.  Customers like Amazon because of the tools like Comprehend Medical and Sagemaker.   Customers like Azure because of its integration with existing Microsoft components. 

Similarly, database functionality such as MySQL or PostgreSQL can be rapidly deployed using a front end service such as Google's SQL Cloud that makes it easy to set up, maintain, manage, and administer relational databases on Google Cloud Platform.

Kubernetes is an open-source container-orchestration system for automating application deployment, scaling, and management. It was originally designed by Google, and is now maintained by the Cloud Native Computing Foundation. 

For healthcare applications, it's clear that Fast Healthcare Interoperability Resources (FHIR) interfaces for inbound and outbound data exchange are the right approach to application/EHR integration.    Highly scalable FHIR services are available via HAPI FHIR on Smile CDR . Google Health's FHIR endpoint is also a good choice.

FHIR is best for exchanging summary data, as well as making EHR data available to an application more broadly.   For HL7 version 2, the Google Healthcare API supports a Minimal Lower Layer Protocol  (MLLP) entry point and a message repository (along with cloud publication/subscription notifications).

And of course, modern network security requires data be stored in encrypted form as well as in transit in encrypted form.  This simple idea will mitigate numerous security risks.

I recently met with well respected industry leaders and asked how Mayo Clinic can future proof its Platform  efforts.    I was told

"Ensure that infrastructure as code is used to deploy storage and compute.   Ensure relational databases can be deployed and managed on the cloud hosting platform.   Use Kubernetes to automate application deployment.  Embrace hosted FHIR and API management services."

As we evaluate new partnerships and collaborations, we do a technical deep dive to avoid locally hosted, siloed, and proprietary approaches, instead favoring a cloud native architecture using Terraform, Kubernetes, and FHIR.

As Wayne Gretzky taught us, you need to skate where the puck will be.    These cloud native architectures are clearly where the puck is going.

The Future of Elder Care

Last weekend I moderated an amazing group of presenters for Harvard Business School's 17th Annual Healthcare Conference, debating the future of elder care throughout the world.

Discussants were

Geoff Price - Oak Street Health, Chief Operating Officer

Susan Diamond - Humana, President of Home Solutions

Neil Wagle - Devoted Health, Chief Medical Officer

 We started with a statement of the problem - in many countries such as Japan, the Nordics, Germany, Italy, and the United States, societies are rapidly aging.   Birth rates are declining.    Costs are rising and access to clinicians is becoming more challenging

 We delved into several major themes - the role of home care, the rise of digital health, and the evolution of financial models that incentivize wellness over sickness.

Mayo Clinic is building home hospital capabilities and, later this year, will evaluate these efforts in two sites.    Through this early work, we'll learn about the supply chain, telemetry, command center capabilities, staffing, and the characteristics of patients best suited to home hospital care. 

 All of the panel members agreed that the future belongs to delivering high quality care in the right setting at the right cost.   Medicare Advantage reimbursement models, accountable care organizations, and alternative quality contracts all focus on reducing total medical expense while sustaining quality/safety/patient satisfaction.     If home hospital care reduces cost while improving outcomes, I believe that refined reimbursement models for home care will emerge.

Delivering digital capabilities - telemetry, communication, and care orchestration to elders requires a comprehensive technology strategy.   Many homes do not have fast, reliable wifi.    LTE and 5G cellular networks will be increasingly strategic for home care.     It's likely that a technology services partner will be needed to keep home-based devices configured, secure and stable. 

Just gathering the telemetry as part of elder home care is not enough.   Algorithms and analytics are needed to turn raw data into action, filtering signal from noise.   It's not yet entirely clear how to understand the precision/accuracy of remote monitoring, how to interpret individual variation, and when to ignore false positive signals.

Mayo Clinic is also launching a remote diagnostics and monitoring capability over the next year, via a platform approach that connects telemetry to novel machine learning algorithms, supporting patient wellness.

We also discussed the digital divide.    As we create more digital interventions to the home, we must meet patients at their level of technology comfort, literacy, and affordability.    We'll need organizations that can help patients access care, optimize the use of devices in their home, and encourage follow through with care plans.   

The future of platform components to enhance elder care is bright and an ecosystem of supportive businesses will be needed.  I look forward to being part of that journey.

Innovation at Work

Over the past 40 years I've worked in a variety of workplace settings, each appropriately serving its intended purpose. I did not appreciate how much a workspace influences my productivity and mood until I starting working at Mayo. My new role focuses on convening stakeholders and facilitating discussion.     A supportive workspace is transformational.

In my mid-teens, I worked in shared office space at TRW (a predecessor company to Raytheon) with large metal desks, filing cabinets and fluorescent tube lighting

In my late teens, I founded a company in a basement and worked at a drafting table next to a bed

In my 20's, while running the growing company and completing my medical education, I worked in a glass walled private office so I could watch the flow of daily activity.

 In my 30's, 40's, and 50's as a CIO, clinician and professor,  I worked in a cube but spent much of my time with customers in other people's offices.

For the past 2 years, I've worked in an open space ad hoc desk/meeting room arrangement that was efficient, attractive, and highly functional. 

Now, as I approach 60 at Mayo Clinic, I work in the most innovative and collaborative space of my career, the recently remodeled Mayo 11 administrative floor. No one on the Mayo senior team has an office - not the CEO, COO, CFO nor Presidents. Everyone uses open plan hoteling desks. The desks are surrounded by huddle rooms and meeting spaces that can be reserved via touch screen or calendar invite. Everyone sees each other every day for hallway conversations. I can ask the CEO any question, any time, by just walking through the space. There's a common kitchen area with meeting tables and healthy food offerings

The furnishings are simple - a kind of Zen functional elegance. Reminders about Mayo's vision, mission and values adorn the walls. The lighting is all 5000K LED daylight.  See photos below.

While rigorous days are common,  the time never feels long because of the richness of human interaction that takes place in the Mayo 11 space.

Per my previous post, my apartment is a 6 minute walk from my bedroom to the Mayo 11 office. I've shaped my new life routine around these living and work spaces for maximal focus and impact. I leave the apartment at 6am, walk 2 minutes to the skyway, which is a heated walking corridor connecting buildings in downtown Rochester. I arrive in the office by 6:10am, have breakfast, write goals for the day in my journal then review the day's presentation materials and agendas. Every 30 minutes from 7am to noon, it's easy to move among meeting rooms, some on Mayo 11 and some in surrounding buildings. A shuttle that runs every 5 minutes takes me to nearby St. Mary's Hospital where I spend time with my clinical and laboratory colleagues. By noon I return to Mayo 11 for lunch and a catchup with my colleagues. Meetings and presentations continue from 12:30pm until evening. The walk back to my apartment passes by a great market, an all vegan restaurant, craft breweries, and a boutique wine store. Dinner is usually a simple bowl of rice, beans and vegetables.  I spend the late evening writing plans and reading the briefing materials prepared by the Mayo Platform team, partners, and collaborators. 

From 7pm on Sunday night until 7pm Thursday night, I'm in Minnesota, living this very productive and satisfying pattern. I return to Unity Farm Sanctuary in Massachusetts by midnight on Thursday. Friday is a mixture of calls, video chats, and writing in my farm office.

On Saturday, I work with the animals and do complicated/time consuming farm tasks from 6am until late evening, completing a task list that my wife writes in a notebook awaiting my return. On Sunday, the morning is filled with less complicated work, leaving me relaxed for my afternoon flight back to Minnesota.

Well engineered, highly ergonomic workspaces make this level of commitment possible in Minnesota and Massachusetts. In 2019 I flew 400,000 miles to 40 countries, while also spending 3 hours a day driving around Boston in traffic. Comparatively, my 5 hour commute to Mayo on Sunday and Thursday is a respite.   

I'm a fan of a life that is constantly self-examined. At this point, I could not ask for a better workplace ecosystem that encourages accomplishment and engagement by design. 

Innovation at Home

This is the first of a two part series that describes where I live and where I work at Mayo Clinic.   

To me, life and work are inseparably intertwined.    You cannot have a productive work life if your home life is unstable.    You cannot have a balanced home life if your work life is unstable.    When I decided to work at Mayo, my wife and I agreed that we would live in Massachusetts running Unity Farm Sanctuary but I would work in Rochester/Jacksonville/Scottsdale Sunday night through Thursday night. 

Over the past month, I've organized a life in Minnesota, maximizing my well-being and efficiency.     I rented a 600 square foot apartment that is a 2 minute walk from Mayo Clinic.   I've moved those things from the farm that make the space uniquely mine - my morris chair, my desk, woodblock prints, green tea supplies, and a simple antique bed. 

Outside the window I can see the Mayo building and the Plummer building.   I'm near a great vegan restaurant and the local food coop.   I have a small stacked washer/dryer in the apartment.    Home Depot is 8 minutes away.   I purchased a used Subaru for airport commuting.

All of this means that I can arrive each Sunday night and drive myself from Minneapolis to Rochester.   Once in my apartment, I can create a simple dinner, write in my journal and prepare for the week ahead.   My bedroom is 10x10 - a perfect place to retreat and rest. 

Monday-Thursday I walk to work (and my workspace is the subject of the next blog) in the morning, spend the day with remarkable colleagues, then walk back to my apartment at night, stopping at the food coop to pick up fresh vegetables for dinner.

Thursday night I drive back to Minneapolis and fly to Boston, getting home about midnight. 

Just as with Unity Farm Sanctuary, I've turned my Minnesota apartment into an internet of things demonstration site.   I have a 100 megabit fiber connection to a Google mesh network.   I replaced the apartment thermostat with a Nest device that I can control remotely, keeping the apartment at 60F when I'm gone but adjusting it to 65F when I'm in town.  I've added smart plugs so that my morning routine turns on lights/music automatically while my evening routine prepares the space for sleep.   The locks are RFID controlled. 

The end result is that I have a stress free, highly functional environment around me when I'm not at the office.    I can cook, clean my clothes, write at my desk, review strategic plans in my chair, and sleep comfortably, all within the 600 square foot layout.    Pictures are attached below.   My many years collaborating with Japan have taught me well and my home space at Mayo is simple, spiritual, and supportive.

Moving Complex Systems Toward a Goal

I recently told several of my Mayo colleagues that I'm an outsider who has landed in a new environment where the degree of collaboration, dialog, and friendly debate is amazing.    The following a kind of guest blog, started by Dr. Michael Joyner, who is also a writer 

He wrote to a number of us

"Great paper written by chairman of bank of England in middle of financial crisis.   Pertinent to anyone interested in nudging complex systems towards a goal."   

Below are the responses:

Let’s move away from risk prediction a bit and apply these concepts to our world.  The world of innovating and translating new solutions (hugely complex and risky) in the medical care industry (more complex and regulated than even the financial industry) to treat human disease (much of it psychological/societal/evolutionary) is off the charts with risk.

I love the statement of fighting complexity with simplicity – it intrinsically feels correct - so what should our heuristics be for advancing medical care?

Modern medical innovation is complex, perhaps too complex. Regulation of modern translation of medical innovation to products is complex, almost certainly too complex. That configuration spells trouble. As you do not fight fire with fire, you do not fight complexity
with complexity. Because complexity generates uncertainty, not risk, it requires a regulatory response plan to enable innovation and translation grounded in simplicity, not complexity.

 So what is our plan and our heuristics?  My suggestion to get us started in honor of Mr. Haldane:

1)    You must move out of the harbor and get in the race in order to win (win being to develop new solutions in medical care)

a.    The race has been underway for some time, so you are behind already, so get going and move with speed

b.    A race is the best analogy – we should move quickly in just about every respect.  “Fail quickly” is a trite but true statement

c.    How many things are stuck in endless cycles of planning or less than serious (not capitalized or staffed anywhere near the need) attempts?

 2)    Almost all of your strategies, plans, predictions will turn out to be incorrect along the way, no matter how much planning you do – you will assuredly have many failures as you progress - how you respond and your ability recalibrate course and keep progressing to the goal is all that matters in terms of achieving success

a.    The good news is at this point you are at least in the race

b.    As with the best entrepreneurs, if you have not failed at least a few times you should not be trusted with anything – very easy to say  and terribly hard to live it when you are deploying capital

c.    The art in all this is determining if the failure is due to execution, if it is then you have the wrong people and should switch out the team – or vision/goal, if it is then time to go back to the harbor.  The first determination (execution) is not too hard to make but hard to execute (needing to switch out the team).

d.    Extremely hard to determine if a group or individual that has failed should be cast aside or given new resources to try again – all of history teaches us that the best folks who we celebrate as geniuses failed many times before succeeding.  Of course, fools will fail as many times as you allow them.

e.    No easy answers here other than did the group or individual at least execute well and move with efficiency and speed, that is necessary component but not sufficient

3)    You should study the strategies and successes and failures of others, but because successes and failures are the result of an enormously complex environment with variables too numerous to count, we should not study them so much or lend them credence to an extent that we “over-fit” our analysis and plan. 

a.    Successes are tainted with survivorship bias – be careful when determining why and how they were successful

b.    Failures are often due to a lack of ability to recalibrate from the inevitable setback or a poor team in charge of executing than a mistake in vision/goal

4)    You will need capital sufficient to start and recalibrate at least twice

a.    Undercapitalization is a guaranteed route to total failure

b.    Perfect Oscar Wilde quote in the article.  We often know the price of everything (salaries and the cost of a team) but the value of nothing (if not a great team staffed as required then we will surely fail, so what are we tabulating)?

5)    The humans involved in the endeavor will override everything else – need to find and bet on the best team possible

a.    All of the above will be evaluated, capitalized, planned, recalibrated and executed by a team of humans – they will determine success or failure

b.    What makes life exciting and fun is that this means complexity and unpredictability – how do we find and support the right folks?  How do we determine that the inevitable failure is the result of the vision/plan or of the humans charged with executing it?  Can we hand additional resources to the team/individual who have failed twice already?  Bill Gates, Steve Jobs and Jeff Bezos, etc. failed many times – what did others see in them to continue to provide resources?

c.    Key question for us all is how to identify and recruit the right team – from the very top to the bottom – and hold all accountable for efficient and effective progress (not success)

----

The Manhattan Project is a great example of survivorship bias – we celebrate it (in a way) because it was successful.  However, that does not mean that throwing $22B and a lot of really smart people at an objective means you will succeed.  Indeed, that approach has failed more often.  It is in the intangibles – I would argue that the sheer pressure that it must succeed (because of the fear of what if we lost that race) meant the accountability and demand for speed was very large – folks got out of the harbor and recalibrated at high speed (or so I imagine).   Pretty hard to re-create that environment – hence the Haldane teaching that it is dangerous to extrapolate characteristics in a complex world

-----

The keys to success when moving complex systems toward a goal are:

1) Engineering problem, not a theory problem.

2) Clear definition of success.

3) Response to a real existential threat.

4) One customer.

Much of what we propose as innovation does not clearly meet any of these criteria.  Manhattan and Apollo did.  The Transcontinental railroad is another example that meets several or all of these characteristics.

-----

And that's what a group of wonderful colleagues debated on a Sunday morning.

Advice for Aspiring CMIOs

Recently, my colleague Steve Peters, chief medical information officer, Mayo Clinic, and I discussed our life experiences as CMIOs.  We talked about how the role has evolved along with changing technology and the transition to nearly universal adoption of electronic health records by large health centers.

 I asked Steve to share his insights on 'what makes a great CMIO in 2020' and captured his thoughts for you.

"I have thought about the 'post-EHR' CMIO as most large centers and hospitals have moved on from the initial implementation.    Here are a few thoughts:

1.       Serves as the primary physician champion for all major clinical information technology projects, including EHR implementation and information security.

2.       Assists in development of IT strategy and planning.

3.       Acts as an advocate for protection of patient privacy and the security of protected health information.

4.       Supports various regulatory compliance activities including HIPAA, Meaningful Use, and billing compliance.

5.       Represents the medical community and serves as an advocate in the promoting the use of information technology in the clinical setting.

6.       Partners with leaders in the effective adoption of information technology solutions in support of clinical care, research and education.

7.       Serves as a physician champion in the development of the electronic medical record and practice management tools.

8.       Maintains an awareness of existing and emerging technology, regulatory, and market factors that have an impact on healthcare information management.

9.       Accountable for the identification, development and execution of education, training programs, and services in the area of computer skills and competencies in the use of electronic tools for patient care, quality, resource management, and performance improvement.

10.  Going back to the 'grandfather' informatics board preparation, I found some broad texts like Biomedical Informatics (Shortliffe and Cimino) very valuable, especially for those areas in which I have less experience or expertise.   The major meetings including HIMSS (from the industry standpoint) and AMIA (more academic) are valuable.    Many areas have regional CMIO meetings to share ideas.   And read blogs."

A New Model for Sharing Insights While Protecting Privacy

Last week at JP Morgan, Mayo Clinic announced a new collaboration with nference that I would describe as "Cloud-hosted, de-identified, federated learning in which the tools are brought to the data instead of sending data to the tools"

 This Healthleaders article describes it well.

 Here's a broad overview.  Let's start with 3 containers.

 The first container is controlled by Mayo Clinic, holds identified data, and has one purpose - the development and optimization of de-identification algorithms. Selected data scientists, who are accountable to Mayo Clinic, are asked to help with algorithms via time limited, audited access to the container.   They are either Mayo staff or collaborators from outside who are trained in Mayo policies and held accountable to the same requirements as Mayo employees.    No data ever leaves this container.

 The second container is a controlled by Mayo Clinic, holds identified data, and has one purpose - running the perfected de-identification algorithms and producing a de-identified data set. That de-identified data set is moved to the third container.

 The third container is for running innovative applications brought to Mayo by partners offering unique analytics on the de-identified data. No data leaves this container, the applications are brought into it. A joint tenancy model enables the container to be run by Mayo Clinic but others to be given limited, audited use of the container to run their applications. The only thing that ever exits the container are data insights or knowledge. For example, if nference is asked a question about drug discovery, its machine learning/natural language processing software in the container can pose the question. The answer is shared but not the data used to generate the answer.

To me, this is the perfect balance of agility, innovation, and privacy protection. I've worked in many organizations and not experienced a design that has so many safeguards against  data leakage. 

We'll populate the third container with our first wave of de-identified data later this year.  I'll continue to report on our progress.

Dispatch from JP Morgan

 Although I've been attending healthcare and technology conferences for more than 40 years (yes, I attended Comdex in 1979), but until this week had never attended the JP Morgan Healthcare Conference.  The conference gathers 60,000 investors, innovators, and providers for four days to plan the next year’s path for healthcare and building relationships that will foster future innovation. I have extensive experience attending HIMSS , which has similar numbers, but only a small fraction actually attend the main the JP Morgan Healthcare Conference.  

My Mayo colleagues and I presented formally in the non-profit track but the remainder of the meetings was dedicated to side conferences in numerous hotels, restaurants, galleries, and office towers.  I'm a practical traveler who walks to most meetings but there was no way to attend 40+ meetings in 30+ locations without help. I had an amazing driver who took me to a different meeting every 30 minutes, adeptly navigating a sea of activity.

Was it worthwhile? What it consistent with my role and mission?

Yes, it was one of the most productive conferences I've attended.

In one city in one sprint of activity, I was able to meet with strategic partners, collaborators, innovators, the press, and stakeholders. I was able to have discussions about complex, technological, challenging, and controversial ideas while reading the emotion of others in the room. I was able to create new friendships and rekindle old acquaintances.  

I've often said that digital health progress depends upon technology, policy and psychology. People ask how I think about contracts and legal agreements for partnerships and collaborations. Although 100+ page documents with appropriate protections are essential, my great hope is that trust and friendships are built so that contracts are signed and never referenced again. Events like JP Morgan are foundational to that kind of relationship building.

Press communications at such events are convenient and productive. If we're going to change the world of health, we need to broadly explain what we're doing, why we're doing it, and how we're putting patients first. All major press outlets are well represented at the conference and were able to talk. I was pleased by the press coverage of the Mayo presentations. 

Finally, JP Morgan enables internal teams to bond and as we divide up the stakeholder meetings, each using our skills and expertise to greatest effect. From 6am to midnight each day we did our best to move our innovation agenda forward.

I remain energized by the optimism of the conference.

How Does a Platform Reduce Barriers to Innovation?

One of our Mayo Clinic Platform team, Emily Wampfler, recently forwarded me an overview of MIT's Platform conference

Read the Barclay's piece.   It notes that 55,000 people changed focus from product support to a platform service line orientation, remarkably enhancing business opportunities.

Few organizations in healthcare have created a Platform which connects data producers and consumers, standardizing security, enhancing reliability and accelerating agility.     What is the urgency to embrace a Platform approach to healthcare?   

 I believe a Platform strategy is the best way to reduce barriers to innovation.   What specific barriers?    I have my own opinions but also asked colleagues like Dr. Craig Monsen, CMIO of Atrius.   Our examples are not related to any single institution we've worked at (Atrius, BIDMC or Mayo) but are drawn from multiple decades of experience in healthcare.

Operational
Innovation efforts compete with staff time required for day to day activities
Innovation efforts may disrupt efforts to standardize work in an organization
Innovation efforts may not be aligned with the immediate goals and priorities of leadership

Technical
Innovation efforts may require data standards that are emerging or not yet implemented
Innovation efforts may require clarification of data use rights 
Innovation efforts may require novel IT infrastructure

Business
Innovation efforts may require significant time investment from IT, Information Security, Compliance and Legal
Innovation efforts may require new policymaking about intellectual property ownership
Innovation efforts may require clarity about unrelated business income for a 501c(3) public charity
Innovation efforts may require finalization of slowly evolving regulations (ONC information blocking rule, CMS interoperability rule)

 Legal
Innovation efforts may require re-evaluating security, privacy, conflict of interest and consent policy
Innovation efforts may require clarification about what projects are operations(as in HIPAA Treatment, Payment, Operations) versus research

What can a platform do to mitigate/eliminate these barriers?

 If senior management (Executives, Board) broadly communicates that a Platform effort will require short term additional work but the resulting standardization of technology, process, and people will simplify future work, then the organization will tolerate the extra effort and disruption.    I think of it like building a house.    Anyone who has ever done a major construction project knows about the dust, delays, and inconvenience of building.   However, when the project is done, there are decades of enjoyment to follow.

 Although data standards constantly evolve, a Platform creates a single place to get/put data using whatever technologies exist today while permitting transition to what's next when it's available.    Although EHR data extraction today may require third party tools or proprietary work arounds, once the data is flowing to a Platform then collaborators can access data via a single point of authorization and authentication  without any dependency on the EHR itself.   I've used this technique to make data available to innovators using FHIR long before FHIR was part of EHRs.   The Platform can embrace emerging standards like FHIR R4 long before such standards are native to the EHR.

 Data Use rights are a key issue and require a consensus of internal/external stakeholders.   I will detail some of the issues about Ethical Uses of data in my next post.   A Platform which serves as a single point of data input/output enables the consistent enforcement of data use policy.

 I recently worked on a project that required a novel business relationship between a 501c(3) Public Charity and an existing EHR vendor.   The business people agreed it would be unrelated business income and would be taxed.    Once a template was developed for unrelated business income arrangements, it was no longer a barrier.  Similarly, intellectual property rights covering developments made using data from a Platform require a standardized policy.   For example, is de-identified data made available for innovation at low cost with the notion that derivative intellectual property creates an ongoing revenue stream OR is the data cost initally high with the notion that derivative intellectual property is unencumbered?  A platform enables easy monitoring and execution of such arrangements

 In sum, a Platform can be an organizing framework for operational, technical, business, and legal stakeholders to create a set of standardized, templated use case variants without having to re-negotiate every new innovation project or collaboration.   In my experience, without a single enterprise approach (call it a single front door) to connecting data producers and consumers, there is unlikely to be innovation agility in healthcare.

In the first 100 days at Mayo, many stakeholders will weigh in on these issues.     I'll report on lessons learned along the way.

Week One

My new role as president of the Mayo Clinic Platform began officially on January 1, 2020.    I was selected for the role in late November and  volunteered time in December to better understand the technology, people and processes of Mayo Clinic.     What will I do in my first weeks at Mayo? 
 
Listen to my colleagues, customers, and staff.
 
I learned a valuable lesson in 1998 when I first became a CIO.   I was seeing patients on a 2pm-2am Emergency Department shift when my Motorola flip phone rang at midnight.    The conversation went something like this
 
    Caller: "Hi, this is Jim"
    Me: "Jim who"
    Caller: "Jim the CEO of the hospitals"
    Me: "Of course, how can I help"
    Caller:  "I've selected you as the next CIO and you start at 8am tomorrow.   We'll figure the rest out later"
 
At 8am I met with three advisors/mentors who agreed to guide me on my CIO journey.   Professor F. Warren McFarlan  of Harvard Business School, John F. Keane the CEO of Keane Inc , and Samuel Fleming of Decision Resources Inc.
 
I explained to them that I'd thought about the IT path forward (for 1998) overnight and we should immediately devote 100% of IT resources to embracing the web for all applications and operations.
 
They looked at me and advised that if I simply told colleagues, customers and staff what I thought they needed, I would have failed change management 101.    Instead, I needed to follow the wisdom of John Kotter and build a guiding coalition empowered by a sense of urgency to change.
 
For the next few weeks, I held listening sessions - over 300 of them.   My mentors were right.  Listening, communicating, and serving the organization based on convening/informal authority was much more potent than using formal authority to command and control.
 
At Mayo Clinic, I had over 50 meetings before I started.    I met with key Mayo partners in industry.  I've had days that started at 6am and ended at 10pm.    And I've just scratched the surface in my understanding of possible futures.
 
In my upcoming meetings I will try to answer 5 questions
 
1.  What unique assets (intellectual property, technology, people, etc.) does Mayo Clinic have?
2.  If the Mayo Clinic Platform were to offer service lines of capabilities, what should they be and who are the intended users?
3.  What economic models are most appropriate to ensure these service lines are sustainable - subscription, licensing, equity growth?
4.  What are the barriers and enablers to creating these service lines?
5.  Are there existing projects that should be halted or de-prioritized?
 
It's becoming clear to me in my conversations thus far that Mayo Clinic has an extraordinary foundation upon which the Mayo Clinic Platform can be built.
 
    30 Petabytes of clinical data
    A large collection of genomes, biological samples and pathology slides
    Numerous state of the art machine learning algorithms
    Faculty expertise
    Access to capital
    A strategic partnership with Google
    Co-development relationships with startups
    A network of affiliates that provide diverse data sources and can serve as pilot sites
    Research in collaboration with established tech companies
    A very strong business development/licensing group
    The reputation of Mayo Clinic
    Connections to innovators worldwide (Mayo opens many doors)
 
After the next several weeks of listening, we'll widely communicate a small number of initial service lines that build on this foundation and projects already in progress.    Remarkable pre-work has been done by Dr. Clark Otley, chief medical officer, who is my partner and who served as interim president of Mayo Clinic Platform and our Business Development colleagues James Rogers, Emily Wampfler, Maneesh Goyal, Andrew Danielsen and Eric Harnisch.    At the upcoming JP Morgan conference January 12-15, we'll be able to announce some of our first partnerships and strategies. 
 
The next year will be a great journey, collaboratively defining the mission, vision and values of the Platform effort, ensuring our products and services are well aligned with the goals of Mayo Clinic and the needs of many internal/external stakeholders, all while keeping the patients first.