Wednesday, August 31, 2016

The Blockchain Challenge

Early this year, I posted a collaborative discussion about the potential applications of Blockchain for healthcare

Ariel Ekblaw from the MIT Media Lab collaborated with BIDMC to actually implement Blockchain medication reconciliation with deidentified patient data.

ONC selected it as a winner of the Blockchain Challenge

The idea is simple.   Blockchain was invented to handle financial transactions such as deposits and withdrawls.

Medication management is very similar to a bank account.  Think of your body as a vault.   When a clinician prescribes a new medication, a deposit is made.   When a clinician discontinues a new medication, a withdrawl is made.    If we add up all the deposits and withdrawls we end up with a perfectly accurate medication list of what you should be taking.

The advantage if this approach is that is does not require complex CCDA parsing or manual intervention to figure out what medication list is redundant, incomplete or inaccurate.   It’s simple debit/credit accounting across multiple sites of care.

I can imagine the same approach could be taken for problem lists, allergy lists, care plans, care teams, and anything that requires reconciliation of multiple lists created at different times by different people.

I highly recommend reading Ariel’s paper.    As we consider new approaches to interoperability, the blockchain concept holds real promise.  Maybe a FHIR enabled API in front of a blockchain driven health information exchange?

Thursday, August 25, 2016

Unity Farm Journal - Fourth Week of August 2016

It’s another “vacation” week for me, which is code for catching up on all business and personal commitments I’ve made over the past few months but haven’t yet completed.   The good news is that I’ll start next week with a clean slate.

Google Maps recently updated their survey of Sherborn, so we have a very current view of Unity Farm.   Here’s what it looks like from above

And here’s Kathy’s hand drawn key so that you can better understand the features in the photograph.

As you can see, the farm is a self contained ecosystem with fruits, vegetables, forest, water, and animals.   We’re at the point where the infrastructure is entirely updated and doing seasonal farm activities every day is a smooth operation.   We are continuing to work on our farm sanctuary 501c(3) ideas and have submitted all the necessary paperwork.    Here’s a summary:

“Increasingly, Unity Farm has taken on an education, conservation, and animal rescue mission.      We often hold classes to instruct members of the Metrowest community in the cultivation of mushrooms, organic pesticide/herbicide free agricultural methods, and chemical free bee care.     Every month, we take on animals from the communiy that others cannot care for because of time, economic challenges, or regulatory constraints.

We wish to establish Unity Farm Sanctuary Inc. to formalize the community education, environmental stewardship, and animal rehabilitation/rescue aspects of our activities. "

Labor Day is just around the corner and that means we're preparing the property for the winter ahead.   We’ll have a few tons of gravel delivered to regrade the farm roads for winter.   We’re winterizing the pig barn with a new door.  We’re doing a long needed upgrade on the heating system to better distribute warmth through the buildings.   We’re touching up painting and stain.    Although this seems like a lot of work, it’s just part of the yearly maintenance of a farm.    Deferred maintenance causes problems quickly and we try to stay ahead of any issues.

The flowers of Summer are fading and being replaced by the flowers of Fall - goldenrod and Japanese knotweed.  Here’s a photo of the bee yard showing the current source sources of nectar.

Our daily harvests are still focused on warm weather vegetables - tomatoes, peppers and basil.   Here’s today’s hoop house harvest.

Finally, there’s a new business  that all farmers with property near golf courses should consider.   The Dowse farm near Unity abuts the Sassamon Trace golf course.  Golfers, especially those in training, have poor aim. The Dowse farmstand now offers “white crabapples”.   I think the yellow/orange ones must be overripe.

Thursday, August 18, 2016

Unity Farm Journal - Third Week of August 2016

I’m on “vacation” this week, working remotely from the farm, so no Wednesday blog post, but here’s the Unity Farm update.

I always tell my staff that management is balancing scope, time and resources.    Too much scope and not enough makes resources very grouchy unless they are augmented.

The same thing is true about managing a farm.   Unless you set a scope that is achievable with the resources you have, the time (defined as the seasons in the farming year), living things, including your own well being, will suffer.

As we plan for 2017, something we’re doing during my slack time this week, we’e set a scope that we believe is achievable with two people (Kathy and me), taking into account our responsibilities to family members, work life, and finances.

*beekeeping (scope = 100 hives, about a million bees, processing 2500 pounds of honey/year)  with a motorized 20 frame extractor, electric wax melter, mobile uncapping table, and bottling tank
*poultry (scope = 100 chickens of various ages, processing 500 dozen eggs/year)

*craft cider (scope = 250 gallons as limited by the production of Unity Farm orchards - about 6000 pounds of apples per year) with a 36L press, a motorized grinder, food grade fermenters
*honey lager (scope = 250 gallons requiring 170 pounds of Kathy’s honey) using 20 gallon stainless steel boiling pots and food grade fermenters
*compost (scope = 10 tons per year, screened and bagged with the custom motorized equipment we built)
*alpaca (scope =5 males and 8 females and 1 guard llama) producing fiber that we spin into yarn
*pigs (scope =1 male and 1 female) eating all the fruits/vegetables that we cannot sell to humans

Kathy and John
*Vegetables (scope = 50x21 foot hoop house and 6 outdoor raised beds growing
Late fall to early spring: optima pelleted lettuce, napoli pelleted carrots, bloomsdale spinach, touchstone gold beets, rainbow chard, garlic
Spring to early fall: marketmore cucumbers, shishito peppers, heirloom tomatoes, japanese eggplant, mold resistant basil, jacobs cattle beans
Cover crops field peas, buckwheat, clover
*Shiitake mushrooms (scope = 500 logs producing 1000 pounds of mushrooms/year innocuated with our self built mushroom processing stand)
*Fruit (scope = 2 acres of Strawberries/Raspberries/blueberries in 3 netted enclosures)

As I’ve said before, farming is like gardening, just at a larger scope.   To put it in perspective, here’s what today’s tomato harvest looks like.  

We’re doing daily deliveries to the farmstand of basil, tomatoes, eggplant, eggs, and peppers.    We’ve spun our summer honey and will start to deliver that soon.

Luckily the blazing temperatures of early August are beginning to wane and the animals are much more comfortable.   Cold weather is just around the corner and they’ll all be healthy heading into the hard months ahead.

Thursday, August 11, 2016

Unity Farm Journal Second Week of August 2016

Running an organic farm means that you have to manage animals and plants in concert with the trials and tribulations nature throws in your path.  You must become an expert on predator/prey, disease/cure, and seasonal variation.  How do you deal with wet/dry, hot/cold, light/dark, insects/rodents, planting/harvesting rhythms etc.

For example we know that flea beetles, which eat eggplant leaves die in July.   Thus we raise eggplant seedlings indoors and plant them in July.

We know what tomato hornworm damage looks like so we can rapidly find the hot dog sized caterpillars and feed them to the chickens.

This week’s issue is black sooty mold on the basil.   Earlier in the season we had aphids on the young tomato plants.   The aphids, by drilling into plant tissues, created a layer of “honeydew” on the leaves that was infected by mold.   That mold spread to the nearby basil and some of the leaves are yellowing.   Our approach has been to spray a very dilute organic sulfur solution (.4%, OMRI certified) on the undersides of the basil leaves, which kills the mold.   When we harvest the leaves, we carefully remove any damage and wash the remaining plants so they are perfect.  Greenhouses and hoop houses can be very humid and shield plants from drying breezes, so it’s clear we need to step up our hoop house airflow to reduce mold problems in the future.

We’re also struggling a bit with cucumber beetle - they disrupt the vascular system of plants and stunt the growth of cucumbers.     We’re spraying with a soap solution every 3 days, but it may be a losing battle.   Our early cucumber harvest was plentiful but this weekend I may remove the cucumbers and replace them with the bibb lettuce we’ve germinated.    For the moment, frogs have moved under the cucumbers to snack on the beetles.

We continue to have many predator visits because of the hot dry conditions we’ve been experiencing this summer.   The coyotes visit every night and the livestock guardian dogs are working overtime to keep them away.    A few of our chickens are solitary wanderers during the day and we’ve lost a few to coyotes/foxes.    Yesterday we did receive .25 inch of rain, so at least the top of the soil is moist.

Our well produces 6 gallons per minute and we’ve been stretching that over our 60 irrigation zones to keep all the orchards alive, but its a struggle.   Just about every town around Boston has a mandatory water ban and even properties with wells are being asked to conserve ground water.    And I thought the Northeast would be a refuge from the drying of the West and Southwest.     Time to take a closer look at Canada…

Over the next two weeks, I’m going to try to work from the farm as a kind of “staycation”   There’s Fall planting, record keeping, and maintenance to do.    There are living things to nuture and extra young guinea fowl to place at nearby farms, as pictured below.   Before the post labor day craziness starts, I’ll do my best to recharge my batteries and get the farm ready for the harvest season ahead.

Wednesday, August 10, 2016

A Visit to Oscar Health

Today I’m in New York City visiting Oscar Health, on my continuing quest to determine how best to integrate digital platforms, patient-family engagement, and care coordination in preparation for MACRA/MIPS and the transformation from fee for service to alternative payment models.

At the moment, there is no single magic bullet, but there are early innovations that hold promise.

At BIDMC we’ve thought the best approach to care management is to identify a cohort with a disease, then enroll that cohort in a program which involves tracking progress against guidelines/protocols, deploying telemedicine/visiting nurses, and measuring data from home-based devices.

Oscar’s approach incorporates similar ideas by providing a unique mobile app and web resources for patients, providers and care managers, reducing total medical expense through informed care navigation.  For example, you are given a choice of options based on your signs/symptoms that aligns the intensity of the service with the intensity of the illness.  Care is coordinated via sharing of clinical and claims data among care teams.   Episodes of care are tracked to ensure patients follow a coherent path.   The technology is superb and the staff is creative.  I hope their startup phase evolves into a long term sustainable business model.

Other interesting technologies to watch are the Salesforce Health Cloud which brings customer relationship management techniques to the caregiver/patient relationship.   Isn’t it ironic that the Ritz Carlton can remember your pillow preferences but your clinician’s office hands you a clip board at each visit to answer the same questions over and over?   Today’s EHRs were designed for documenting episodes of sickness, not encouraging wellness.    The concept of customer relationship management in healthcare is what I call “Care Traffic Control” - setting goals for the patient then ensuring those  goals are tracked, reviewed and discussed.

Apple's CareKit  is another technology to follow since it enables care planning, care team communications, and care progress monitoring all on your phone.    BIDMC is launching its first CareKit app when iOS10 is released this Fall.   The app - a version of BIDMC@Home that includes HealthKit, CareKit and BIDMC Patientsite features all in one platform, is something I believe will bring true value to patients and families.

The next two years in healthcare will be rocky - the end of Meaningful Use, the transition of presidential administrations and the release of final rules from CMS that will shape reimbursement for the next 5 years.     The winners will be those health systems that respond to these disruptions with agility.    The time to begin selecting the tools you’ll need to manage wellness, control medical expenses, and treat patients as customers is now.

Thursday, August 4, 2016

Unity Farm Journal - First Week of August 2016

The farm refrigerator is 25 years old and this weekend it finally failed.   It had two working temperatures - too hot and too cold.    After 25 years of hard work it had to be retired, since spare parts are no longer available.   The new refrigerator arrived today and our cold chain is up and running again.

Tomatoes and peppers are plentiful - here’s what one morning’s harvest looks like.

All our tomatoes are heirlooms, grown organically.   For example, we do slug control on the Cherokee Purples by placing bowls of beer in the bed to attract pests and keep them away from the tomatoes.    The slugs have a preference for Sam Adams.    The only spraying I did all season was a light soap solution (OMRI listed) to control aphids.      We’re doing farm stand deliveries to Tilly and Salvey’s in Natck every 2 days because demand for fresh tomatoes and basil is high.

Fall is just a few weeks away so we are getting ready.   We grind all our old mushroom logs into mulch for the 1.5 miles of trails on the farm.    As I’ve said before, farming is just like gardening, but at a larger scale.   Here’s what the freshly ground mulch pile looks like - about 5 tons ready to spread on the trails.

The young guineas and chickens continue to learn their way around the farm  - exploring every ecosystem.  They seem to prefer to cool forest undergrowth immediately adjacent to the barnyard where they are protected by the geese and roosters.

Our meadow is filled with wild turkey babies - about 20 of them.   They love the tall grass.    Three moms are protecting the young turkeys that range in size from baseball to basketball height.

We’ve had some rain this week - about .3 inch.    The drought is still upon us, but at least the ground is moist and the trees are less stressed.

This week I finished the two year Umass Certificate program in organic farming.   Since it’s my 7th academic credential, my wife has declared that I’m in 37th grade.
As I wrote in yesterday’s post, learning never stops.

This weekend will be filled with vegetable harvesting including our Jacob’s cattle beans, trail maintenance, and planting Fall seedlings.   Although it’s August, I can tell the days are getting shorter and we’re getting closer to the change of pace that occurs every year post labor day.   I always look forward to the change of seasons and the cool days ahead.   The pigs are not quite sure since they asked to be tucked under their blankets last night after the 60F chill of dusk

Wednesday, August 3, 2016

My Guiding Principles

As I’ve aged and matured my approach to life, career, and family, I’ve evolved my rubric for organizing each day.    Here’s what I’ve used for 2016

*Minimize lost time
Avoid commuting delays as much as possible - leave no later than 6:00am in the morning and return either before 3pm or after 7pm.   I generally go in early, return early, care for animals, then work in the evening.    I work in Boston Tuesday/Thursday, in our suburban Metrowest office Monday/Wednesday and wherever the most urgent projects are happening on Friday.

Limit airline travel to impactful events - I have numerous federal/regional/state commitments and used to fly to every one.    Now I assess the impact of the meeting and limit travel to one day a month.    This Fall has an unusual cluster of international travel - Denmark, New Zealand, and Israel, all related to collaborations around interoperability and security.

 Be virtual whenever possible - Although high intensity meetings are best attended in person, standing meetings with people you already know can be done effectively by phone.    A one hour phone meeting is a much better use of time than a one hour commute, a one hour meeting and another one hour commute.

*Do satisfying activities that make a difference each day - doing a job you love is directly related to happiness, longevity, and domestic tranquility.  

*Family comes first - careers can be changed, but family is forever. To keep my family members happy and healthy, I must help my daughter establish a self reliant future, help my wife achieve her goals, and ensure my mother (the last surviving parent) can do fulfilling activities in a stress free living environment

*Be Well - personal health directly impacts my performance in all aspects of life.   Each day includes at least an hour of exercise (generally related to farm activities) and sound nutrition (vegan for 20 years).   I strive to improve life processes, fixing whatever is broken, be that a machine, a schedule, or a relationship.    I never stop learning and experimentation.

*It Takes a Village - there are too many tasks in too little time to do them all yourself.    It’s important to share burdens, whatever they may be.   None of us are an island and we need to constantly learn from others.    Regardless of what happens each day, there is a process for everything to get to a better place.

Those 5 principles have worked me in 2016.   No doubt, 2017 will refine this further.  I never know what tomorrow will bring, but I’m confident each day will be better than the last.