Unity Farm Journal - First Week of November 2014

When you’re a farmer, you’re often faced with the life, death, and sickness of those living things who depend on you.

Recently, my father in law was diagnosed with a Stage IV Neuroendocrine Tumor on the head of the pancreas.  Ironically, it’s the same disease that Steve Jobs experienced.   Chemotherapy began this week and we’re hopeful that shrinking the tumor will relieve some of his symptoms.   Cure is unlikely and many difficult decisions await us.

With Stage IV cancer, surgery is not an option.

If we do nothing, the highly aggressive tumor will cause rapid decline - weight loss, weakness, and susceptibility to falls/infections.

If we proceed with full cycles of chemotherapy, there may be reduction in tumor burden improving life quality or there may be side effects that make the situation worse.

We’ll work hard to respect all of his wishes on the journey ahead.  Chemotherapy and medications are meant to be palliative.   If complications occur, it’s likely that he will want minimal intervention.

He lives at the farm and needs to climb a few stairs, which is increasingly difficult,   We’ll need to think about mobility solutions, home care assistance, and possible relocation of his living spaces to the first floor.  We’re heading into cold and icy weather, so likely we’ll have to build a wheelchair ramp in and out of the house.

Having experienced the death of my father in March of 2013, the end of life process is still fresh in my mind.     As Atul Gawande outlines in Being Mortal, we’ll focus on life quality, not quantity.    My father-in-law and the dynamics of the entire family are paramount.     We’re rethinking the pattern of our duties and our activities.  I return to Boston from Europe tomorrow and I will not travel for the remainder of 2014, deferring all distant meetings and speaking responsibilities.   We’ll take each day one at a time, and I’ll creatively juggle my time using Skype, FaceTime, and teleconferencing to balance home/family needs with work needs.   My colleagues and BIDMC leaders are all very supportive.

Each of us will die.     The goal is to ensure that death is dignified and pain free.     My wife’s battle with breast cancer led to remission.    My father-in-law’s experience of pancreatic cancer will include the entire spectrum of emotion, from sadness to love and hope.   For now, medication, hydration, and spending time together is the most compassionate care we can deliver.

Unity Farm Journal - 5th Week of October 2014

One challenge of being a farmer is that the animals, plants and infrastructure need you 24x7x365.   This Fall, I’ve had to travel to China (last week) and will be in Europe (London, Berlin, Copenhagen, and Amsterdam) next week.

Last weekend was filled with catchup for the time missed and preparing for the time to be missed.

Luckily, the farm was buzzing with activity - my daughter and her partner David, David’s parents,
 and Kathy were all able to join me for farm work.     Our tasks were

1.  Crush 450 pounds of apples.   We made 3 batches of hard cider, two of which will be for drinking and one of which will be cider vinegar for next year’s Unity Farm pickles.   Our small batch methods are labor intensive but we have total control of the process, ensuring a perfect blend of apples - sweet, tart, aromatic, and astringent.   This crush involved a combination of Spencer, Golden Delicious, Baldwin, Macoun, McIntosh, and Northern Spy.   I've moved the cider to our mud room since the cold nights could result in a stuck fermentation.

2.  Plant 4000 ginseng seeds and 100 ginseng roots in 1000 square feet of forest.   American Ginseng  (Panax quinquefolius) is a tricky plant to grow given its unique habitat requirements - a forest slope of 10-25% grade, covered in maple/oak/ash, with 70% shade, in moist leaf humus that is not too moist.    I raked a 1000 square foot area of the forest, clearing rocks and roots, then placed the roots at a 30 degree angle to the surface, cutting a v-shaped trench with a shovel.  I created  a template to plant 4 seeds per square foot over the area.   Then we spread 50 pounds of gypsum over the plantings, to add calcium, and covered the soil with 3 inches of leaf mulch.     We should see ginseng sprouts in the spring, and have harvestable roots in 6-8 years.   Why do this?  Part of goal at Unity Farm is forest farming with ginseng, paw paw, black cohosh, goldenseal and other challenging crops as part of permaculture - sustainable crops that have resale value.

3.  Plant 600 cloves of garlic - every October we plant hard necked garlic (about 10 different varieties) outdoors so that it can set roots, over winter, and the begin growing as soon as the Spring thaw arrives.   We harvest garlic every July and use it in the majority of our cooking/canning.    This year we created 7 beds and used a template to set the cloves in perfect 6 inch rows, 2 inches deep.   When then covered the beds with salt marsh hay to keep digging animals out and heat/warmth in.

4. Pick raspberries, turnips, daikon, beets, and peppers - all our crops are mature at this point and needed to be picked before the first freeze.   We picked a bucket of raspberries, a bushel basket of turnips, a picking box of daikon, an armful of beets, and a double peck of peppers.      Kathy combined fresh daikon, Japanese mibuna greens, and Japanese chrysanthemum leaves into a wonderful daikon soup pictured below.     The mushrooms continue to fruit and many of our Shitake logs are covered with emerging fungi.   The meadows are filled with shaggy manes, wine cap, and champignons.  Pictures are below

5.  Herd health - all the animals received their inoculations and we released our final flock of 8 week old guineas.   We have 68 to overwinter, so I built extra roosts in the coop.   Our 50 bird coop can now accommodate 80 birds and our multiple generations of guineas have bonded together as a single flock.    The mornings are crisp and the compost piles are steaming

At the moment, the farm is entirely ready for my absence next week.    The plants and animals are prepared for the possibility of snow and the harvest is complete, although we’ll continue to grow greens for the next few months.  2014 may very well be the last time I accept extensive foreign travel commitments.    Occasional trips are fine, Skype is better, and the farm needs my nights/weekends.

The Changes at ONC and Next Steps

In 2014, there have been many changes at the Office of the National Coordinator.

Although I do not have access to an organizational chart, I believe the leadership of ONC and the changes in 2014 are as follows

National Coordinator: Karen DeSalvo (Named Acting Assistant Secretary of Health)
Deputy National Coordinator: Jacob Reider (Leaving in November)
Office of Care Transformation:  Kelly Cronin
Office of the Chief Privacy Officer:   Lucia Savage
Office of the Chief Operating Officer:   Lisa Lewis (Named Acting National Coordinator)
Office of the Chief Scientist:  Doug Fridsma, MD, PhD (Became CEO of AMIA)
Office of Clinical Quality and Safety:  Judy Murphy, RN (Joined IBM)
Office of Planning, Evaluation, and Analysis:  Seth Pazinski
Office of Policy:  Jodi Daniel
Office of Programs:  Kim Lynch (Leaving in November)
Office of Public Affairs and Communications:  Peter Ashkenaz
Office of Standards and Technology:  Steve Posnack
Interoperability Portfolio Manager: Erica Galvez

Although some have voiced concerns about loss of momentum, I believe that in change there is opportunity.

ONC has a served as a catalyst, accelerating the adoption of electronic health records by hospitals and eligible professionals.   Guided by the certification regulation, EHRs now include robust interoperability for public health reporting, transition of care exchange, lab result incorporation, patient/family engagement and quality data submission.

We’ve achieved a new baseline that did not exist 4 years ago.

Now it’s time for the private sector to step up and lead the charge on the next generation of interoperability - query/response based on FHIR, OAuth2/Open ID, and REST.   We need two implementation guides - one for document level exchange and one for data element exchange of the Meaningful Use Common Data Set (see the last page of this document)

A coalition of the willing - vendors, HL7, providers, program management, and champions from the private sector can keep the momentum going as we all drive to a new set of FHIR specifications in 2015 - a second Draft Standard for Trial Use based on lessons learned with the first draft standard.

Over the past few days, I’ve seen new energy and enthusiasm for accelerating interoperability, following the roadmap described by the Jason Task Force.

Rahm Emanuel said “You never let a serious crisis go to waste. And what I mean by that it's an opportunity to do things you think you could not do before.”

The combination of change at ONC, the Jason Task Force report, and new private sector urgency for interoperability is a perform storm for innovation

I think the weeks ahead will be filled with rich discussion about how all stakeholders can unify to accelerate the efforts already in progress.     It’s truly time for a new optimism 

Unity Farm Journal - 4th week of October, 2014

While I was in China at the beginning of the week, Kathy maintained the farm and all its activities.  

To prepare for Monday’s night’s frost, she picked all the mushrooms from our Shitake logs.   Subtypes Miss Happiness, Native Harvest, and Night Velvet are all fruiting in large quantities.   We’ve developed Unity Farm branded packaging using recyclable cardboard containers and a small amount of perforated shrink wrap.    Kathy has been delivering mushrooms to local farm stands in my absence.

Before my departure I picked another peck of peppers, so we now have a pair of pepper pecks which Kathy chose to pickle.    She used our homemade apple cider vinegar and this simple recipe

On last week’s flight to Washington I read a great book about farming in the forest.  Since Unity Farm is about half forest, the notion of planting paw paw seemed very appealing.   So, this weekend we’ll plant paw paw and pack the pair of pickled pepper pecks.

Forest farming in the Northeast can also include American Ginseng, which although rare, grows near spicebush and jack in the pulpit in the Unity Farm forests.  Kathy ordered 75 one year old ginseng plants and 500 seeds which will plant in 5 test areas around the forest - north woodland, mid woodland, south woodland, north orchard, south orchard.  We’ll watch their growth carefully and then add more ginseng to the successful areas.  Ginseng is a slow grower and we’ll have to wait 6-8 years to harvest mature roots.

Now that Unity Farm is built, we’re entering the phase of daily operations - actively farming the forest, managing the trails, inspecting the bees, planting the hoop house, pressing cider, and caring for the animals.   Our to do list looks like this

Forest  -  farming crops,  thin/plant trees, marketing mushrooms
Trails - managing vegetation
Bees - inspecting, feeding, honey bottling
Hoop House - planting, weeding, harvesting, preserving
Orchard  -  pressing cider, making cider vinegar, canning Unity Blue (our blueberry, raspberry, elderberry jam)
Alpacas/Llamas - monthly care, yarn making
Poultry - monthly care, eggs

The path from farm to table is a daily process, always focused on the future harvest and working backwards to the tasks of today.      The leaves are falling and the seasons are changing fast.  The approaching winter will give us time to catchup on indoor tasks, ordering seeds for next year, and reflecting on our lessons learned.

The weekend ahead is filled with planning our ginseng crops,  pressing cider, planting garlic, herd health, and harvesting turnips.    I look forward to getting my hands in the soil instead of sitting on planes!

Dispatch from China

On Monday and Tuesday I met with government, industry, and academic stakeholders  in Qingdao and Shenzhen China to discuss healthcare technology,  patient empowerment, and process improvement in the rapidly expanding Chinese healthcare system.    Here's a photo of my visit to a hospital pharmacy in Shenzhen, dispensing ginseng and ling chi mushrooms.

Over the past few years, I’ve watched the Chinese government gradually change policy - from promoting a fully public healthcare system, to limited pilots of private facilities, to embracing public/private partnerships.

Foreign entities can now directly invest and operate joint venture hospitals in China, while Hong Kong and Macau based investors can own and operate hospitals in selected cities.

China faces the same challenges as the US and other industrialized nations - an aging society, increased demand for care, a limited supply of qualified professionals, shrinking budgets, and the need to improve quality.

I outlined a 5 fold approach for China

*Innovation in healthcare technology - universal adoption of EHRs, health information exchange, big data analytics, cloud delivery of services, wearables/mobile for patient/family engagement
*Education/Culture of Quality - ensuring every clinician has access to best practices and feedback on the quality of their practice
*Reputation building - creation of a regional center of excellence well known for  outcomes, great teaching, and cutting edge research
*Recruitment of mentors, mid career professionals and early achievers - to foster a supportive community of practice
*Public Health/Health Services research - to provide every clinician with the tools needed to support continuous wellness , population health, and care management.

As the American century draws to a close and China becomes the world’s strongest economy, collaboration between the US and China in the science of healthcare delivery will have mutual benefits.  

As I told the mayor of Shenzhen (below), my wife is Korean, and based on my love of the Far East, I am an Asian at heart.

I look forward to ongoing collaboration which improves the quality, safety, and efficiency of healthcare in China.

Wikipedia and Facebook for Clinical Documentation

Over the past several years I’ve written about the inadequate state of clinical documentation, which is largely unchanged since the days of Osler, (except for a bit more structure introduced by Larry Weed in the 1970s) and was created for billing/legal purposes not for care coordination.

One of the most frequent complaints in my email box these days is a sense that the current record is filled with data, but little knowledge and wisdom.  It’s hard to understand each patient’s individual story.   Notes are filled with cutting/pasting, inaccuracies, and redundancy.   Sometimes among the dozen notes written each day by the medical student, resident, fellow, attending, and consultants there is inconsistency.

The era of Ebola has accelerated the urgency for us to rethink the way we document.

In recent lectures, I’ve called on the country to adopt Wikipedia and Facebook for clinical documentation.

I don’t really mean that we should use those products, but we should embrace their principles.

Imagine if the team at Texas Health Presbyterian jointly authored a single note each day, forcing them to read and consider all the observations made by each clinician involved in a patient’s care. There would be no cut/paste, multiple eyes would confirm the facts, and redundancy would be eliminated.   As team members jointly crafted a common set of observations and a single care plan, the note would evolve into a refined consensus.   There would be a single daily narrative that told the patient story.     The accountable attending (there must be someone named as the team captain for treatment) would sign the jointly authored “Wikipedia” entry, attesting that is accurate and applying a time/date stamp for it to be added to the legal record.

After that note is authored each day, there will be key events - lab results, variation in vital signs, new patient/family care preferences, decision support alerts/reminders, and changes in condition.

Those will appear on the “Facebook” wall for each patient each day, showing the salient issues that occurred after the jointly authored note was signed.

With such an approach, every member of the Texas care team would have known that the patient traveled to Dallas from West Africa.     Every member of the care team would understand the alerts/reminders that appeared when CDC or hospital guidelines evolved.   Everyone would know the protocols for isolation and adhere to them.    Of course, the patient would be a part of the “Wikipedia” and “Facebook” process, adding their own entries in real time.

Yes, there are regulations from CMS enforcing the integrity of the medical record.    I’ve had preliminary discussions with folks in government who have signaled that as long as the “Wikipedia” authorship takes place outside of the medical record and then is posted/signed/timed/dated by a single accountable clinician, regulatory requirements will be met.  Once posted, the entry cannot be edited/changed, just amended, preserving data integrity.

It’s likely that the “Facebook” portion of the display would not be regulated,  but would require the same kind of validation we already do for lab result workflow.   The "wall" could also be certified for the Meaningful Use provisions that require viewing of the Meaningful Use Common Data Set.

Once there is a single place for all care team members to look when treating a patient, decision support based on analysis of structured and unstructured data will be easier to engineer.

Although I believe that the medical record coding we do today will become less relevant as we evolve from fee for service medicine to global capitated risk, the use of computer assisted coding and clinical documentation improvement tools will be easier with the “Wikipedia” plus “Facebook” approach.

I can even imagine that emerging Fast Healthcare Interoperability Resources (FHIR) work could represent the “Wikipedia” entry as part of document retrieval standards and the Facebook wall could be part of discrete data query/response, providing a timeline for the key events in a patient’s treatment.    I’ve already discussed the need for such timeline data with key FHIR architects.

A team at BIDMC is working on clinical documentation, structured and unstructured, in FY15. We’ll proceed incrementally, learning from each phase, and begin our journey toward an inpatient record that looks more like Wikipedia and Facebook than Osler’s notebook.    As Ebola and the tide of EHR dissatisfaction drive innovative documentation thinking, we'll need to move deliberatively.

And if we’re lucky, care team members will rekindle the spirit of working and talking together instead of starting at a screen, checking boxes for Meaningful Use.  

Unity Farm Journal - Third Week of October 2014

Apple Season continues.   This weekend we crushed 152 pounds of apples yielding 8 gallons (2.2 gallons per bushel), down a little from our last crush which yielded 2.4 gallons per bushel, likely because Baldwin apples are less juicy than McIntosh.

The ph was 3.2 (a little more acid than usual) and the specific gravity was 1.050, yielding 6% alcohol.

Baldwin 55%  (Sweet)
Macoun 13% (Aromatic)
McIntosh 24% (Tart)
Crab 8% (Astringent)

We’re fermenting this batch indoors since the nightly temperatures in Sherborn are now falling into the 30’s, which can result in a stuck fermentation.

We racked our last cider batch and added malolactic bacteria.

Thus far, our cider production is proceeding flawlessly - with a year of experience under our belt, we’ve found our rhythm.

The Shitake mushroom logs are ready for an enormous fruiting over the next 2 weeks. Unfortunately, I will be in Washington, Philadelphia, Beijing, Qingdao, Shenzhen, Seattle, London, Berlin, Copenhagen, and Amsterdam on the weekends (yes, that’s a lot of red eye flights), so Kathy and I are dividing up the labor, with me doing all the hauling, cutting, and heavy lifting around the farm on the nights I’m there while she takes charge of the mushroom harvest, packaging, and delivery to local farm stands.    This is our first year of harvesting commercial quantities of mushrooms, so we’re learning every day.

The hoop house is thriving with the warm days and cool nights of Fall.  I’ve picked a peck of peppers (not pickled yet) - hungarian banana, poblano, and japanese chili pepper.   Here’s what a peck of peppers looks like:

All the animals are well - the dogs are growing their winter coat, the chickens have molted, the ducks are eating vigorously to prepare for the weather ahead, the alpaca are enjoying sunny cool days, and the bees are completing their winter honey stores (about 70 pounds of honey per hive).   My travels begin tomorrow and I’ll be caring for the menagerie by Skype for 4 days.