Thursday, January 30, 2014

Building Unity Farm - Automation Arrives

Over the past few months, I've asked a dozen farmers what automation is best for Unity Farm's 15 acres of woodland management, manure movement, trail maintenance, food storage, and orchard harvesting.    I received thirteen different answers ranging from:

Buy John Deere, Kubota is underpowered

Buy Kubota, John Deere is mostly outsourced

Buy from your closest dealer, service really matters

Don't worry about the dealer, do the service yourself

Buy Agricultural tires, they're absolutely necessary

Buy Industrial tires, since Agricultural tires will wreck your property

Buy a skidsteer/compact track loader for work in mud/snow and on hills.   A tractor is for pulling not pushing

Never buy a skidsteer/compact track loader, they lack flexibility.

What did we buy and why?

I know that at least 11 farmers will disagree with me, but we bought a Terex PT30 Compact Track Loader, pictured above in our orchard.    It weighs 3000 pounds, lifts 950 pounds, yet only has 3 PSI pressure on the ground, leaving the trails and turf untouched.   The machine is the evolution of the ASV RC30 and has an advanced track system that does not slip in mud or snow.  

To make the decision, I test drove several devices.   With the PT30, I was able to move 12 cubic feet of mulch, haul 400 pounds of logs up a 15 degree slope, clear the orchard road of snow, move 500 pounds of rocks, and execute numerous zero turning radius redirections on snow in less than 45 minutes.

Unity Farm is a "compact farm" with one mile of trails that are 5 feet wide.   I really do not want to widen the trails, since their current width gives an intimate feeling of being deep in a forest.    The PT30 works on all our trails and turning around in 5 feet is no problem.  Try that with a tractor.

Unity Farm has many slopes, rocks, roots, gates, and narrow passages around outbuildings.   I was able to drive the Terex through all of the them.

This weekend, I'll move a few thousand pounds of wood and a few cubic yards of mulch around 15 acres.   When I told the salesman that I had already moved 10000 pounds of manure, 10000 pounds of logs, and 10000 pounds of mulch with a wheelbarrow and wagon, he asked "are you nuts?".    The answer to that question could be debated.

Unity Farm was built by hand labor, but now that I'm almost 52 years old, I look forward to the automation as I move thousands of pounds around the property every weekend.

Admittedly that Kubota tractor did look appealing, so I did buy one…for my desk.

Another Unity Farm update.   I lecture frequently at Harvard Business School and write for Harvard Business Review (HBR).    My Harvard students and colleagues often asked me, "why didn't you go to 'B' school"?

They're completely right and I'm going to correct this deficit by enrolling in a nighttime executive  'B' school this semester.

I'll learn about Bee biology, site selection, hive manipulation, four seasons management, honey extraction, and disease control.

In addition to my degrees from Stanford, UCSF, UCLA, Harvard, and MIT, I'll proudly add the 'B' school certificate to my CV this April.

Wednesday, January 29, 2014

Management Lessons Learned from A Game of Thrones

A Game of Thrones is the first novel in A Song of Ice and Fire, a series of high fantasy novels by American author George R. R. Martin.

I rarely watch television, but for Christmas, my wife bought me Season 1 of  Game of Thrones, the HBO series inspired by the novels.  Don't worry, this blog post will not contain any spoilers.

Watching the characters jockey for power and influence reminded me of my experience navigating organizations over the course of my career.   Here are my top lessons learned from the series:

1.  Doing the right thing does not always work

I have strongly believed that the nice guy can finish first and that in the long term those with strength of moral character will triumph.    In Game of Thrones, some of the moral characters are outfoxed by manipulative, cruel, and deceptive characters.   One character notes "When you play the game of thrones, you win or you die."     I have no plans to change my personal philosophy or approach to life, but it is interesting to reflect that some battles cannot be won with honor if your opponents are truly evil.

2.  There should be alignment of authority and responsibility.

One character notes "The man who passes the sentence should swing the sword."   It's easy for management to make decisions when someone else has to implement them.  Over the course of my career, I've been careful to "eat my own dog food" using the products I'm responsible for creating, making hard decisions then executing them, and taking responsibility for consequences that even indirectly result from my actions.   In organizations where there is a disconnect between authority and responsibility, chaos reigns if you lack authority to manage change in your areas of responsibility or if you have authority but are not responsible for your actions.

3.  You need to choose your goals and stick to them.

One of the characters is torn between honor and family.   He does not know whether to stay with his new colleagues (as he as sworn to do) or travel to aid his family in a time of war.   He struggles with the decision and for a time pursues neither goal.   Eventually he chooses honor and is "all in" with that goal, knowing that many others will assist his family and all will be well.

4.  Strategy matters.

In the series, an extremely wealthy family attempts to win a war by being better resourced.   Another family with fewer resources strategically outmaneuvers the wealthy family by building alliances and separating their forces into two contingents, using the element of surprise to achieve victory.     Good planning is just as important as good execution.

5.  You can't predict the future, but you can react to events around you to make the future.

One of the characters is a young and untested leader, willing to grow and make thoughtful decisions as she gains experience.   Events occur around her beyond her control.   She reacts to them calmly and in the best interests of others.  Eventually circumstances change and she seizes the opportunity to move beyond her formal authority, creating loyalty with the informal authority derived from her unique abilities.

We all grow over time and engage in own Game of Thrones at a micro level as we journey through our careers.   Many of the characters in Game of Thrones and in our workplaces are morally ambiguous.   I live each day knowing that I cannot control the behavior of others, only my reaction to it.  Guided by my values, I've been able to achieve little victories in the game of life.

Thursday, January 23, 2014

Building Unity Farm - Winter Fermentations

It's the dead of winter in New England, with new snow on the ground and temperatures near zero.    The animals are clustered together in their barn spaces and heated buckets are keeping their water liquid.

There are many indoor tasks to do on the farm during winter - sharpening chain saw chains and other tools, reorganizing the workbench, ordering seeds, planning for Spring planting (we've been tractor shopping), and nurturing all the fermentations begun in the Fall.

Our fermentations include 3 kinds of cider, mead, cyser (a mixture of cider and honey), vinegar, sourdough,sauerkraut, and fermented pickles.   Here's an overview

1.   Cider, Mead and Cyser

Although we bottled 4 cases of sparking cider in the Fall, we still have 12 cases in the fermenters.    Fermenter #1 is a Champagne Yeast fermentation of 11 different kinds of apples kept at 52F in our mudroom to prevent Malolactic fermentation.  The malic acid in apples is a dicarboxylic acid with a sharpness/crispness that I like in a sparkling cider.  Think of it as the flavor of a green apple.    When I make sparkling cider, I add 6 grams/liter of dextrose at bottling to prime the cider for carbonation.  The malic acid and dextrose create a harmonious flavor that's very refreshing.   I typically have a 16 ounce bottle of sparkling cider with lunch on weekends.   After 2 months of aging, the ph of this cider is 3.75 and the malic acid taste is very notable.

Fermenter #2 is a Champagne Yeast fermentation of 11 different kinds of apples with added Malolactic bacteria culture.   After two months, the ph of this cider is 4.15, much softer and smoother given that most of the malic acid has been converted to lactic acid, which has only a single carboxyl group.  I'll bottle this cider uncarbonated - as still cider.   Malolactic fermentation changes the flavor a bit, adding the kind of butteriness you taste in most Chardonnays.

Fermenter #3 is a Champagne Yeast fermentation  of 11 different kinds of apples with added Malolactic bacteria culture.   The yeast has exhausted many of the nutrients in the cider due to a Keeving process  I used during the initial fermentation.  It's fermenting very slowly and I believe I will end up with a smooth cider with a small amount of residual sweetness.  I'll bottle this cider uncarbonated as well.   The ph of this Cider is 4.07.

The taste among the three is remarkably different and we'll see which one is best once I bottle them in the Spring.

The mead and cyser fermentations continue.   At the first racking, the specific gravity of the mead decreased from 1.090 to 1.030, yielding 8% alcohol.    The specific gravity of the cyser decreased from 1.085 to 1.010, yielding 10% alcohol.   We'll continue fermentation until the Spring and bottle them uncarbonated in 375ml clear wine bottles once fully fermented to a specific gravity of 1.000.

2.  Apple Cider vinegar

I separated 20 liters of hard cider from the other fermenting batches, added mother of vinegar  and stored it in the basement, open to the air.   When it is finished, the titratable acidity will be 5%.  It's currently at 2% and has a remarkable flavor without being overpowering.

3. Sourdough
We use the King Arthur Starter and keep buckets of active sourdough growing in our mudroom.

4.  Sauerkraut
We use a 5 liter Harsch crock and weights with the following recipe

3kg of cabbage
15 grams of salt

Remove wilted outer leaves of cabbage head, and the stalk. Shred cabbage.

Layer the cabbage, sprinkle some salt then press down with a fist until juice appears. Repeat until pot is full.

Lay on the weights and if there is not enough juice, add cooled boiled salt water (15gm salt per liter ratio)

Close lid, then add plain water to the rim (water trap)

Leave pot at room temperature for 3 days until you hear some bubbling.

Move to a cooler room for 4-6 weeks

Move into large Ball jars in the refrigerator.   Eat within a month.

5. Fermented Pickles

We use a food grade 2 gallon bucket and a plate on top as a weight
2 pounds freshly picked firm, unwaxed, bumpy pickling cucumbers, often called Kirby
2 cloves spring garlic, sliced thin
1 dill flower, or 5 sprigs fresh dill or 1 teaspoon dill seed
1/2 teaspoon coriander seed
1/2 jalapeño, seeded and slivered
2 tablespoons salt

Soak cucumbers for 30 minutes in a bowl filled with ice water to loosen any dirt. Slice the blossom end off each cucumber, which is opposite the stem end. If you aren’t sure which end is which, slice a little off each. Cut cucumbers into spears or chunks, if desired.

Pack cucumbers into one or two clean quart jars. Tuck in garlic, dill, coriander and jalapeño, if using.

Add salt to two cups boiling water. Stir until dissolved. Add two cups of ice (made with filtered water if yours is chlorinated). Stir well until the ice has melted and the brine is cool. Pour brine into jars, covering cucumbers.

Loosely cap jars and place in a bowl or pan because the jars may leak during fermentation.

Leave pickles on the counter to ferment. The brine will bubble lazily and become cloudy. Taste after 3 days, leaving on the counter another day or two if you want your pickles more sour, or refrigerating if they’re ready. They keep a month in the refrigerator.

It's time to put another log on the fire and listen to the subtle bubbling of our winter fermentations.

Wednesday, January 22, 2014

Advice to the New National Coordinator

Karen DeSalvo started as the new National Coordinator for Healthcare Information Technology on January 13, 2014.   After my brief discussion with her last week, I can already tell she's a good listener, aware of the issues, and is passionate about using healthcare IT as a tool to improve population health.  

What advice would I give her, given the current state of healthcare IT stakeholders?

1.  Rethink the Certification Program -  With a new National Coordinator, we have an opportunity to redesign certification. As I've written about previously some of the 2014 Certification test procedures have negatively impacted the healthcare IT industry by being overly prescriptive and by requiring functionality/workflows that are unlikely to be used in the real world.   One of the most negative aspects of 2014 certification is the concept of "certification only".   No actual clinical use or attestation is required but software must be engineered to incorporate standards/processes which are not yet mature.   An example is the "transmit" portion of the view/download/transmit patient/family engagement requirements.   There is not yet an ecosystem for patients to "transmit" using CCDA and Direct, yet vendors are required to implement complex functionality that few can use.   I completely support the idea of "transmit", but it should have waited until the ecosystem was mature enough to make it an attestation requirement.  Another example is the use of QRDA I and QRDA III for quality reporting.   CMS cannot yet receive such files but EHRs must send them in order to be certified.   The result of this certification burden is a delay in 2014 certified product availability.   Certification should focus on rigorous interoperability testing, using mature standards, in practical use cases, supported by the evidence and experience.

2.  Evaluate the collective timelines of Meaningful Use, ICD10-CM, ACA and the HIPAA Omnibus Rule - Thousands of pages of regulations are hitting the industry at the same time and it's clear that like, haste will make waste.   My suggestion - extend Meaningful Use Stage 2 Year One attestation by 6-12 months (not just delay Stage 3 a year as has already been done) to enable clinicians to install certified software, redesign workflows, be properly trained, and educate their patients about the new functionality available.   I realize this may be a regulatory leap, but I've seen new rule making done as corrective action in the past.  Although I believe ICD10-CM requires more testing (the CMS planned March testing is not enough) and most applications will not contain the clinical documentation improvement features needed for clinicians to adequately justify the new codes, most hospitals have put so much time and resources into ICD-10-CM projects that they cannot afford to extend the project beyond October 1.  For ACA, re-evaluate quality measure submission requirements per point #4 below.   For the HIPAA Omnibus Rule, rethink the accounting of disclosures scope and timing.

3.  Declare victory for Meaningful Use -  Stage 1 of Meaningful Use was a phenomenal success.   Adoption rates of good EHRs by hospitals and eligible professionals has tripled.   Public health reporting and interoperability are accelerating.   Awareness of security issues has markedly improved.   Stage 1 was seen as a tide floating all boats.   Stage 2 was greeted with less excitement.   It exceeded the capacity of many organizations from a technology, policy, and workflow perspective.  It has been described as a burden that has slowed innovation, consumed industry resources, and co-opted local agendas for quality improvement projects.   However, it has many benefits and those gains can be captured with enough time.   By the end of Meaningful Use Stage 2, hospitals and eligible professionals will have reached a breaking point in their capacity to absorb regulatory burdens, so we have to progress beyond 2017 very thoughtfully.   If our policy goals are outcomes based, then we should offer a Stage 3 regulation which enables organizations to qualify for incentives if outcomes are achieved using IT as an enabler.   We should not prescribe specific functionality for the EHR other than interoperability and security.  As noted in point #1, focusing on certification and attestation for interoperability is reasonable as long as there are no "certification only" functions mandated.     We should eliminate penalties for non-compliance with Stage 3 and return EHR innovation to customers and vendors.   Meaningful Use will have succeeded if we capture the gains of Stage 1 and 2, then focus on Stage 3 incentives that drive us to better outcomes, rather than penalizing providers for not checking more attestation boxes.

4.  Fund pilots and research -  We are on the cusp of a sea change in interoperability, population management, and clinical decision support.   CCD led to CCDA which leads to FHIR for content summary exchange.    The Direct protocol will evolve to a RESTful interface using OAuth/OpenID for trust fabric creation.   However, we're not going to make the move to FHIR and REST unless pilots (followed by agile development of implementation guides) are funded to enable incremental progress.   FHIR is too new and REST has too many industry skeptics.   The pilots will create a tipping point which mitigates risk and enables progress.   Also, two of the great challenges in informatics - automated quality measures (QueryHealth and HQMF) and nationally curated decision support (Health eDecisions) would benefit from pilots.   In point #1 I noted that we need mature standards but at present our quality measurement and decision support standards are immature.   If we pilot them and revise them, we'll mitigate risk and can consider the use of quality and decision support standards which are optimized for purpose in future interoperability certification.

5.  Continue the ONC convening function for standards, privacy/security, and hearings to capture lessons learned about adoption/implementation -  ONC provides a very important and unique convening function in which issues can be discussed by multiple stakeholders.   There will be an ongoing need for standards selection and revision, bridging the work of standards development organizations and clinical stakeholders.   Privacy and security policy is informed and improved through national debate of the issues.   Evaluating the successes and shortcomings of the EHR related regulations is important to future refinement.   I suggest that ONC/CMS limit their regulatory focus on Meaningful Use requirements related to mature interoperability standards and privacy/security (as noted above), and focus much more on bridging gaps in five key areas:  a)  ONC versus CMS (certification versus attestation); b)  HHS versus CMS (disparate quality measure and other reporting requirements within the HHS domain); c) the government versus market (vendors and providers); d) vendors versus providers; and e)  providers versus patients.  In practical terms, this would focus less on a core belief that 'all EHRs should do X, Y and Z' to a focus on 'given what we are learning about an ever-evolving market (e.g., new payment models, new delivery models such as Patient Centered Medical Home, new technologies, new patient engagement models, etc), what EHR interoperability needs, quality measures, and privacy/security safeguards are needed.'

It's a fragile time at ONC when the excitement of the ARRA/HITECH funded grant programs has passed, many people have departed, and Congress is wary of IT projects in general.

Karen is the right person for the job at this time in history, just as her predecessors were the right people for their eras.   She can regain the trust of Congress, make midcourse corrections to the Meaningful Use program, and balance the burden/benefit on stakeholders.   If she can rebuild a city's health system after Katrina, she can polish those elements of the ONC strategy that experience in the marketplace has deemed to be necessary.

Thursday, January 16, 2014

Building Unity Farm - The Sounds of Unity Farm

Since moving to the farm in April of 2012, I've posted many pictures of our efforts to create a working farm in Sherborn, Massachusetts.   Although it's winter, the farm still bustles with activity.   To give you a sense of what I experience every morning as I walk through the barnyard tending to the creatures, I carried an Olympus USB audio recorder with me on a recent morning.

On the front of the farmhouse we have a rain chain in lieu of gutters that drains into a cistern to capture water.    It was raining during my recording you'll hear my walk from farm house, past the rain chain, to feed the guinea hens and ducks.

After feeding the ducks and guineas I sat with the chickens for a few minutes and fed them scratch grains.   Our two roosters decided to compare their voices.

The duck pond was thawing as the temperatures warmed and I spent a moment clearing the ice so that the birds could enjoy open flowing water.

I brought fresh lettuce from the hoop house to the birds  and placed it in a large rubber bowl so all the animals could enjoy a taste of summer during the winter.   The guineas squawked with joy as they crunched the leaves.

The northern border of Unity Farm is mixed forest and wetlands.   The western border is the Dowse apple orchard.  The southern border is another farm.   The eastern border is the CSX rail line (map below) for slow moving freight trains that travel between Framingham and Foxboro.   At 7am, 12:30pm, and 2:30pm and 11:30pm, we hear the gentle rumble of a freight train in the distance, 10 acres away through our forest.   Here's what the morning train sounds like from the barn.

Every season brings new sights and sounds on the farm.  This spring many migratory birds will return and nest at Unity Farm.   This summer, we'll experience the birth of several baby alpaca.   The Fall brings the rustle of falling leaves.   More sound posts to come!

Wednesday, January 15, 2014

The Roles I Play

As 2014 begins, I marvel at the evolution of the CIO role from 1997 to 2014.   Gone are the days when my role was to serve as technical expert, configuring web servers, optimizing data bases, or simplifying code.   Gone are the days when product decisio nmaking depended on software architecture expertise to ensure scalability, reliability and security.   Gone are the early wins of the "bold moves" like replacing Lotus Notes with Exchange, Novell with NT, Sybase with Microsoft SQL, and client/server with web applications.

Here are a few examples of the roles I play today from the past few weeks

1.  Rethinking a challenging project by ensuring all stakeholders understand the key roles/responsibilities assigned during project formation i.e.

Defining the business champion
Defining the executive sponsor
Defining the role of IT
Defining the role of the project manager
Defining the support model
Defining the responsibility for creating, managing, and maintaining interfaces
Assigning responsibility for workflow/process definition
Assigning responsibility for vendor relationship management
Writing the governance committee charter
Defining the communication plan for internal and external customers
Defining unit testing and integrated testing responsbilities
Defining the training/education plan

2.   Convening local government and provider stakeholders to agree on a single approach for public health reporting that aligns meaningful use stage 2 requirements, healthcare information exchange timelines, and affordable care act planning.   We needed consensus on scope, timing, and technical details so that local government efforts are complementary rather than competitive to the regulatory "must dos" of 2014

3.  Presenting the BIDMC Enterprise IT strategy to senior leaders of the hospital and professional groups, so that all stakeholders understand the options, the decisions make thus far, and linkage between business requirements/IT tactics.

4.  Serving as master of ceremonies for the statewide health information exchange public demonstration, ensuring all involved institutions were showcased to highlight their strengths.

5.  Assisting with the development of new policies and procedures such as those involving privacy, healthcare information exchange and use of social media in healthcare

In 2014, the my work role has evolved to convener, communicator, mediator, navigator, and load balancer instead of technician, architect, programmer, informatician, and clinical expert.    Not that the evolution is bad.  In the modern era, we all have about 5 careers in our lives.  What's amazing to me is how many careers I can have without changing my position as CIO!

I recently wrote a column for Information Week, Boiling the Frog describing some of the challenges all CIOs face as their roles evolve.   As we begin 2014, I have the recovery time afforded by the holidays behind me and I'm approaching my role with new optimism.   The chaos and stress of 2013 is behind me.    I'm ready to thrive as I focus on using my evolving skills to make those who report to me as successful as possible.

Over the holidays I completed two books which will be published in the next few weeks, codifying everything I've learned in my CIO roles over the past 20 years.   One is a 400 page edited, revised, and indexed reflection on the themes of my blog.    I'll be doing a book signing at HIMSS.  The other is a 250 page fictional thriller co-written with a prominent Italian healthcare system CIO and containing many elements inspired by the IT events I've experienced over the past few years.   More to come as they are published in paper and e-book form.

Thursday, January 9, 2014

Building Unity Farm - Thinking about Automation

Every year at Unity Farm, I move 10000 pounds of manure, 10000 pounds of logs (18 inch segments), 10000 pounds of wood chips, and thousands of pounds of snow.    I've done this to date using a hand cart and wheelbarrow.    I turn 52 in a few months and its time for automation.

But, what's the ideal device?   We have hills, forests, meadows, mud, ice, and grass.

A tractor such as the Kubota B3200HSD seems reasonable with industrial R4 tires that provide traction without too much damage to underlying soil.   John Deere offers a competitive model of tractor, the 3032E.

However, many of the trails at Unity Farm are narrow and the manure access is via a crusher rock access path about 5 feet wide.  Are there alternatives?

Many have recommended a compact track loader such as the Bobcat T110.

Others have recommended the Terex PT30

Track loaders provide maneuverability and good hill climbing capabilities, but they can be rough on grass.

My answer - I have to experiment with each machine.    Since they vary in price from $16000 to $25000 (0% financing for 5 years may be available), it's best if I "test drive" them.

For $200 per day, I can rent these devices from local dealers.   I can move manure, wood, rocks, and mulch.   I can run them up and down hills in a variety of conditions.

To me, the device design/engineering is important but access to dealer service is also critical.

The Kubota/Terex dealer is 12 miles away.  The Bobcat dealer is 35 miles away.   The John Deere dealer is 35 miles away.

I'll report back on my experiments with moving, hauling, and transporting around Unity Farm.   I welcome input from others on comparing Kubota, John Deere, Bobcat and Terex.

Wednesday, January 8, 2014

The Next Phase of Healthcare Information Exchange

Today, Massachusetts Governor Deval Patrick will launch the next phase of healthcare information exchange (HIE) in Massachusetts - “Commonwealth Interconnected:  Mass HIway Query and Retrieve

In Phase 1 of our state HIE project, we focused on the Meaningful Use Stage 2 Direct protocol, enabling transition of care summaries, public health reporting transactions, and labs to flow over a state operated secure infrastructure.

In Phase 2, we solved a much harder and more complex problem - the pulling of records in real time from physician offices and hospitals where patients have opted in to disclose their records to other caregivers.

This required the engineering of several components
*A state wide master patient index for patients who opt in, storing name, gender, date of birth and other demographic data elements
*A state wide consent registry indicating the medical record numbers and locations where patients have opted in to disclose their data to caregivers
*A portal which enables providers to securely login and view patient medical record locations
*A viewer which enables secure retrieval of medical records from organizations which support real time data display
*An electronic medical record request system for those organizations which support a request/release by the medical records department workflow.
*Full audit trails of all activity - an accounting of disclosures

Today a multi-organizational team will demonstrate an Emergency Department visit by a febrile, confused, elderly gentleman.   His records are scattered over many hospitals and clinician offices.   Treatment in an emergency room is accelerated, more aligned with patient/family care preferences, and is safer with more information.   We'll demonstrate how a single institutional record based on one episodic visit can be very different than a lifetime continuous record which includes the entire patient experience with healthcare.     We'll show several near misses with diagnostics and therapy that could have caused harm, increased expense and reduced quality.

Today is the launch of the service.   The state's master patient index and consent registry (collectively called the relationship locator service) will be populated as patients consent to be included.   57 organizations including providers, public health, health plans, local HIEs and clinical registries are already part of the Massachusetts HiWay and all will be working hard in 2014 to expand the use of the new services.

I can imagine a day in the next few years, when all patients in the Commonwealth, with their consent, benefit from secure, coordinated care.    My mother suffered a major medical error in California because of inaccessible primary care records.   I truly believe that my 20 year old daughter, attending Tufts University, will see significant reduction in preventable harm in Massachusetts during her 20's.

Let the safety begin!

Saturday, January 4, 2014

Baby, It's Cold Outside

For those who not have experienced Winter Storm Hercules , it's currently -10F at Unity Farm (not wind chill, that's -15F).    We have 10 inches of new fallen snow.

As I've written about previously, all the animals have protection from wind and water.  Wall mounted heaters are protecting them from frostbite.      At dawn we gave the alpaca and llama large bowls of alfalfa mixed with molasses.   The chickens and guinea fowl ate hot oatmeal mixed with dried cherries.   The ducks got a warm duck soup of chopped greens and warm water.    The dogs got an extra helping of their favorite dog food.   The rabbit got a very sweet banana.

Here are a few photos at -10F from Unity.    Yes, an iPhone 5S works well at that temperature, although fingers using the phone do not last long.

I added bricks to the top of the bee hives to prevent the covers from blowing off.   We added sugar feeders to the inside of each hive and replaced the hive opening with a very small "winter" front door.  A capping of snow insulation is keeping them warm.    

We refilled every bird feeder, ensuring our juncos, chickadees, bluebirds, wrens, finches, titmice, woodpeckers, cardinals, and nuthatches have maximal nutrition.

The cider house is keeping all the apple picking and beekeeping equipment safe from the elements.

We shoveled all the paths and gates for easy access to the coops and paddocks.

The hoop house is a balmy 28F, keeping our winter vegetables growing by trapping the heat of the sun.

The blowing snow drifts created Zastrugi in the orchard 

The pastures are covered with a blanket of snow.   After 2 years of moving snow, mulch, and manure with a hand drawn wagon, I'm finally considering a tractor.

Shiro, our 120 pound Great Pyrenees male, has very big paws for scrambling through snow.

The duck pond is frozen and covered with snow, although the water is still circulating below the surface.     The ducks bathe in their 50 gallon stock pond that is heated to 40F.

We dug out the garden shed to access all our snow management tools.

Shiro kept a close eye on everything during the storm.

We removed the roof from the mushroom house to keep it from collapsing under the weight of ice and snow.

We have three mushroom "laying" yards where fruiting logs are kept for harvest.   At this time of year, the only creatures exploring the laying yards are deer, rabbits and foxes.

The dogs are begging for a run on the trails, but at the moment only deer are running through the 10 inches of loose powder.

I've split 8 cords of wood for heating this winter.   We'll use half a cord during the duration of Hercules and the freezing days to follow.

Stay warm!

Thursday, January 2, 2014

Building Unity Farm - Making Mead and Cyser

The entire family visited Unity Farm for the holidays.  After all the gift giving, merry making, and
yuletide time by the fire was over, what should a family do at a farm with apples, honey, fermentation equipment (there's a basic chemistry lab in the cider house), spring water, and microbiology know-how?   Make mead of course!

Mead was the earliest fermented beverage created by man - evidence of honey and fermentation products begins about 9000 BC.   Mead figures prominently in Hindu writings, the work of Aristotle, and the Old English poem Beowulf.  

There's a new vocabulary to learn when deciding how to make Mead.

"Show" Mead - a higher alcohol, full flavored mead made with more honey and less water
"Small" Mead - a lower alcohol, lightly flavored mead made with more water and less honey (Queen Elizabeth the First enjoyed a very dilute mead)
Melomel - mead with added fruit or fruit juice
Pyment - a melomel made with grapes and often herbs.   You could call it a honey-fortified wine
Cyser - a melomel made with apples.   You could call it a honey-fortified hard cider
Zythos or Braggot - a mead fortified with malt.   You could call it a honey-fortified beer
Morath - a melomel made with mulberries
Metheglin - a mead made with herbs or spices.   The name means "Mead of the Glen".   Some believe it is the root of the term "medicine"
Rhodomel - a metheglin made with roses

At Unity Farm, we tend to prefer our beverages fermented dry.  We often create both sparkling and still versions of our beverages, but I only make still mead after a bad experience with exploding bottles as a mead maker in my 20's.   Here's the approach we used during the holidays:

Unity Farm Mead
 3 quarts water from our 600 foot deep well
 3.5 cups Unity Farm Orchard Honey (wildflowers and clover)
 1 teaspoon acid blend (citric/malic/tartaric acids)
 5 grams Redstar Pasteur Champagne yeast
 6.25 grams Go-Ferm yeast nutrient in 125cc's of 110F water
 10 grams of Fermaid-K

Heat the water to 160F, add the honey and acid blend.   Simmer for 10 minutes and do not boil.   Skim any foam from the top.   Pour into a 2 gallon sterilized fermenter (we use food grade buckets with a drilled lid and airlock, pictured above).    Take a ph or specific gravity measure if you wish.   Our 12/29/13 batch had a specific gravity of 1.090 and a ph of 3.43, giving us a potential alcohol level of 12%

Add 6.25 grams of yeast nutrient to 125cc's of 110F water.    At 104F add the yeast and wait 15 minutes.   Cool 100cc's of the honey/water solution to 104F and add it to the yeast solution.   Wait 15 minutes.   The resulting yeast solution will be frothy with new yeast growth.

When the honey/water solution in the fermenter is 104F add the yeast solution.    Place in a room with a constant temperature in the low 60's for slower, more flavorful fermentation.

After 1 day, add 5 grams of Fermaid-K

After 1 week, add 5 grams of Fermaid-K

After 2 weeks, rack the solution with a racking cane into a sterilized gallon jug and seal it with an airlock.  Leave very little air space  in the jug (1/4").  Top up with water if necessary.  After 2 months, sterilize the mead with 50 parts per million of potassium metabisulfite, then bottle and age for 6 months before drinking.

Unity Farm Cyser
 1 quart water
 2 cups Unity Farm Meadow Honey (wild asters and japanese knotweed)
 1 teaspoon acid blend (citric/malic/tartaric)
 1 cup black tea (steeped 3 minutes at 200F)
 2 quarts Unity Farm unfiltered Apple Cider (made from 11 types of apples)
 1/2 teaspoon pectic enzyme
 5 grams Redstar Pasteur Champagne yeast
 6.25 grams Go-Ferm yeast nutrient in 125cc's of 110F water

Heat the water to 160F, add the honey, acid blend and tea.   Simmer for 10 minutes and do not boil.   Skim any foam from the top.   Pour into a 2 gallon sterilized fermenter.    When the mixture has cooled to 110F, add the cider and pectic enzyme.

Take a ph or specific gravity measure if you wish.   Our 12/29/13 batch had a specific gravity of 1.085 and a ph of 3.56, giving us a potential alcohol level of 11.3%

Add 6.25 grams of yeast nutrient to 125cc's of 110F water.    At 104F add the yeast and wait 15 minutes.   Add 100cc's of the honey/cider/water solution to the yeast solution.   Wait 15 minutes.   The resulting yeast solution will be frothy with new yeast growth.

Add the yeast solution to the fermenter.    Place in a room with a constant temperature in the low 60's for slower, more flavorful fermentation.

After 1 day, add 5 grams of Fermaid-K

After 1 week, add 5 grams of Fermaid-K

After 2 weeks, rack the solution with a racking cane into a sterilized gallon jug and seal it with an airlock.  Leave very little air space  in the jug (1/4").  Top up with water if necessary.  After 2 months, sterilize the mead with 50 parts per million of potassium metabisulfite, then bottle and age for 6 months before drinking.

Although we've not enjoyed the flavor of commercial melomels, we will create our own blueberry, raspberry, and elderberry melomels this summer when the berries are ready.

Mead is an acquired taste and you will want to experiment with different styles to find the right mead for you.   Hence I recommend 1 gallon batches that enable you to evaluate each recipe variation but not create an overabundance of something you'd prefer not to drink.

Happy mead making!

Wednesday, January 1, 2014

The Year That Was 2013

As the year drew to a close, I was interviewed by many trade publications about the key themes that shaped 2013.   Here's my own version of the notable events of 2013.

1.  Meaningful Use changed the EHR landscape
Regardless of your political affiliation, there is little debate that EHR adoption in the US achieved a tipping point in 2013.   Here are our Massachusetts statistics from the 2013 Massachusetts Medical Society survey

The current overall percentage of EHR use is 79% (N=201, CI=5.6) and 82% of those using EHRs have had access to this technology for more than 2 years. Extrapolated to the estimated 18,000 clinical physicians in the state, that would leave less than 3,500 clinical providers without access to EHR systems (3% of respondents indicating that they are no longer in practice).

Broken down by practice size adoption rates are:
1-9 Physician practices made up 66% of respondents and had an adoption rate of 75%
10-25 Physicians practices made up 13% of respondents and had an adoption rate of 96%
26-75 Physicians practices made up 6% of respondents and had an adoption rate of 100%
>75 Physicians practices made up 12% of respondents and had an adoption rate of 97%

2.  Healthcare Information Exchange developed great momentum
Meaningful Use Stage 2 and more importantly the Affordable Care Act motivated organizations to implement push (via Direct and HISPs), pull (via regional and state HIE activities) and view (among clinical affiliates) interoperability for care coordination and population health.   As a CIO, I'm no longer the lone voice driving interoperability top down, it has become a bottom up demand.

3.  Security and privacy became Board-level issues
Meaningful Use, compliance requirements, and enterprise risk assessments elevated security and privacy issues to top priority for many organizations.  CIOs are hiring new security staff, enhancing capabilities, and expanding budgets to address increases in threat sophistication and volume.

4.  Self built EHRs became increasingly rare
Partners Healthcare and MD Anderson adopted Epic.   Intermountain Healthcare adopted Cerner.  That leaves Beth Israel Deaconess and the Marshfield Clinic among the few healthcare organizations building applications to enhance innovation and reduce cost.    An unintended side effect of Meaningful Use Stage 2 certification criteria was that provider self built systems, niche specialty applications, and small EHR vendors all became rare.

5.  Innovation slowed as the regulatory combination of ACA, ICD-10, MU2, and HIPAA Omnibus rule dominated the agenda for IT organizations.

The work I've done on Natural Language processing, Google Glass, advanced analytics, workflow enhancement, and patient/family engagement was limited to nights/weekends and the strength of will of selfless volunteers who innovated outside the workday.

As Meg Aranow guest posted on my blog in 2011, the content of being a CIO in 2013 continued to be great, but the context became even more anxiety-provoking .   Demand exceeded supply, anxiety/tension escalated, and budgets became even more constrained (except for selected security/compliance projects, which are often seen as burdensome rather than beneficial by customers).  The holidays brought a welcome reduction in post traumatic stress disorder symptoms for many CIOs I know.    However, on the positive side, I've always felt that times of great struggle are opportunities for greatness.   We are living in the most transformative time for healthcare in the US, and the worsening CIO stress is just a side effect of accelerating change for all healthcare stakeholders.   I recently wrote about the mitigations we need to consider to get through each day.

Personally, 2013 was a combination of emotional highs and lows.   My father died in March.   My mother entered a new chapter in her life requiring resilience and new skills.  My wife's cancer is in remission although she still experiences the side effects of chemotherapy, peripheral neuropathies and muscle spasms, that impact her activities of daily living.   My daughter thrived at Tufts University in 2013, maintaining her own apartment, living independently, and viewing the world with increasing sophistication.

Unity Farm continued to grow in 2013 with 11 chickens, 10 ducks, 29 guinea fowl, 11 alpaca, 1 llama, 2 Great Pyrenees Mountain dogs, 3 cats, and 1 rabbit in perfect health.  2013 was the year our orchard was born, the cider house was built, our duck house/pond was created, and we established a regular routine for efficiently managing all 15 acres of woodland, pasture, and wetland.   We obtained various licenses and certifications to begin selling our jams/honey/cider/mushrooms/vegetables and learned a great deal about producing organic, handcrafted products.

The combined responsibilities of leading IT for a growing ACO, assisting several countries with IT strategic planning, working on US national standards, championing state healthcare information exchange adoption, and being a Harvard Professor strained my endurance at times, especially early in the year when I made 5 visits to California around the time of my father's death.   Trips to China, Japan, Taiwan, and London were all important, but required boundless energy to ensure my day jobs were fully supported while I was half a world away.   2014 will have much less travel than 2013.

I turn 52 in a few months and as I reflect on the year that was 2013, I can say it was one of the most difficult on the journey thus far.  However, at the end of the year I feel the trajectory heading into 2014 is right.   The healthcare environment will still undergo tectonic shifts but my family, friends, and colleagues will make it navigable.    I will reaffirm my quest for equanimity in all difficult situations, my veganism, and my balance of work/farm life.    May 2014 be happy and healthy for all of you and enable you to make a difference.