Unity Farm Journal - Fourth Week of December 2015

Last week I mentioned the Unity Farm Christmas list.

I’ve been an avid student of permaculture - creating an ecologically sustainable farm that keeps everything in balance.    I harvest thousands of pounds of vegetables per year but compost  the imperfect vegetables..   There must be a better way.

Hazel Marie is the answer.

Welcome the latest addition to Unity Farm, our 100 pound pot bellied pig.  We rescued her (as we have done with several of our farm animals) from a home which abandoned her to the MSPCA/Nevins Farm.   She is a delight with a constantly wagging tail, boundless energy and curiosity about the world around her.    I plan to walk her around the property on a harness and she’ll live in one of our pastures in the newly finished pig barn.   Last weekend I added heated water buckets, a panel heater (pig safe) and interior LED lighting.

My daughter, Lara Marie, approves of Hazel Marie as our official surplus vegetable consumer.   We will find Hazel Marie a piggy companion once we have more experience with pigs.    We really like Patches, a 200 pound male recently surrendered to Nevins Farm, but he will grow to 800 pounds.   We’re not sure we can handle that much pig.   Kathy’s Christmas gift to me is Hazel.

Kathy has had significant joint pain and neuropathy since her chemotherapy.   Hauling hundreds of pounds of bee hives around our 15 acres has been difficult for her.   Although I’m 53 and relatively fit, I find hauling hundreds of pounds of lumber, tools, mulch, vegetables, and firewood around the farm to be fatiguing too.    The Terex front loader is great for rocks, mushroom logs, snow, manure, and wood chips, but it’s not something you drive casually for transportation.    The answer - a golf cart utility vehicle.   My Christmas gift to Kathy is a Yamaha Adventurer One, a golf cart with a 300 pound hauling capacity for her to to drive around the property and do all the things she wants to do, regardless of any physical limitations.

What about stocking stuffers?   I asked Kathy for Havahart vole traps so I can reduce the damage to the hoop house vegetables during the winter when small furry creatures take refuge in the vegetable beds.    I also asked for a labeler/gluer that enables me to put formal labels on all our cider, beer and mead bottles.

Finally, for the family, I finishing the build out of the treehouse I started in the summer.   Although a platform without railings 15 feet in the air sounds great to me, it’s not appealing to everyone.    Here’s the progress thus far turning the platform into a finished 12x12x12 foot cube, suspended in air but accessible via a 3 foot staircase protected by railings.    In Spring I’ll add a roof.   I think the family will like it.

Although Christmas day will be 60 degrees, we’ll soon have the chill of January, so I’ve tucked the vegetables into their raised beds with row covers.   Here’s what the hoop house looks like now.

The farm is looking festive as we approach the holidays.    The cider house has wreath under the barn light, as does the barn, the tool shed, and the house entrance.

The inlaws, outlaws, and all our close family will be at the farm for the next few days.    We’ll revel in the warmth of the season, each other’s company, and gentle sounds of geese, pigs, dogs, alpaca, ducks, chickens, guinea fowl, and cats all living in harmony at Unity Farm.

And to all a good night!

My 2016 Predictions for HIT

As the year ends and we archive the accomplishments and challenges of 2015, it’s time to think about the year ahead.  Will innovative products and services be social, mobile, analytics, and cloud (SMAC)?  Will wearables take off?  Will clinicians be replaced by Watson?   Here are my predictions

1.  Population Health will finally be defined and implemented -  Recently I asked a number of clinicians to define population health.   Although no one could define it, they were sure that their current EHR did not provide the desired functionality.    To me, population health tools in 2016 will automatically aggregate data from multiple provider, payer and patient sources then create lists of patients with care gaps to be closed.    This article in Harvard Business Review illustrates some of the functionality we’ve built at BIDMC in anticipation of 2016 needs.

2.  Security threats will increase - Two weeks ago, the Attorney General for National Security from the Department of Justice visited Boston to meet with a group of CIOs and CISOs, describing the escalating number and sophistication of cybersecurity attacks.   He concluded that if a device is internet connected, it will be compromised.   At BIDMC, we will continue to invest millions in security technology, rewrite many of our policies and invest in continuous security education for all our staff.   Despite our best efforts, I cannot promise a breach-free year in 2016.

3.  The workflow of EHRs will be re-defined.   In 12 minutes, can a clinician enter 200 structured data elements, manage 140 quality measures, be empathic, never commit malpractice and make eye contact with the patient?   Nope, it’s impossible.   This Wall Street Journal piece illustrates the problem

The EHR must evolve from a fraud-prevention tool in a fee for service world to a team-based wellness tool supporting alternative payment models.    I’ve told CMS that the ideal EHR will be a combination of Wikipedia (group authored notes) and Facebook (you’ll have a wall of health related events)

4.  Email will gradually be replaced by groupware - Managing daily email is a burden with minimal rewards.  Facebook has announced Facebook for Work to provide enhanced communication among teams, supported by enterprise grade security.    I receive over 1500 emails a day and might declare email amnesty in 2016 (an out of office message declaring email to be an ineffective communication medium and suggesting that I will never respond)

5.  Market forces will be more potent than regulation - Meaningful Use has accomplished its goals.   MU is dead, long live MU.   We need to move away from prescriptive regulations so complex that no one understands them.  Instead, we need pay for performance based on outcomes, giving providers and industry the freedom to achieve these outcomes using whatever technology they feel appropriate.

6.  Apps will layer on top of transactional systems empowered by FHIR - Epic, Cerner, Meditech, Athena, and eClinicalWorks are all fine companies.  However, will the next great app be authored by their staff?   I’m guessing a better approach is crowdsourcing among clinicians that will result in value-added apps that connect to underlying EHRs via the protocols suggested in the Argonaut Project (FHIR/OAuth/REST).   One of our clinicians has already authored a vendor neutral DICOM viewer for images, a patient controlled telehealth app for connecting home devices, and a secure clinical photography upload that bypasses the iPhone camera roll.    That’s the future.

7.  Infrastructure will be increasingly commoditized - In 2016, I will be moving select applications to Amazon and Google.  They can offer a better/stronger/faster/cheaper service because of their scale than I can do myself.    They are willing sign Business Associate Agreements.   Why do I want the risk of operating multiple data centers myself for commodity services like web hosting?

8.  Less functionality with greater usability will shape purchasing decisions -  Recently a clinician told me that EHR A has half the features of EHR B, therefore EHR A is twice as good!   Remember Wordstar and Word Perfect?  Try authoring an outline in the most modern version of Microsoft Office.    Prepare to have your work destroyed by feature bloat in Office.   Clinicians want usability, speed, and simplicity, not more features.

9.  The role of the CIO will evolve from provisioner/tech expert to service procurer and governance runner - From 1996-2001 I wrote many of the foundational applications of Beth Israel Deaconess.   My education at Stanford, UCSF, UC Berkeley, Harvard, and MIT enabled me to innovate rapidly as a clinician, domain expert, and engineer.  Today I do not write code and my role is to empower/enable talented people around me with funding, protected time, and political will.    The CIO of 2016 will increasingly be an orchestra conductor and not a technology expert.

10.  The healthcare industry will realize that IT investments must rise for organizations to meet customer expectations, survive bundled payment reimbursement methods, and create decision support/big data wisdom - I often tell my stakeholders that scope, time and resources are tightly coupled.   You cannot increase scope without increasing time or resources.    As more automation is deemed critical for the needs of the business, IT budgets will be increased as a strategic imperative.   There will be a tension - the CFO will want to increase capital budgets (purchasing of stuff) while the CIO will want to increase operating budget (purchasing of services and subscriptions to cloud functionality)

That’s my top 10 list.   And no, Watson, will not replace clinicians, although Natural Language Processing is a technology to watch in 2016.   Other companies will do it better than IBM.

Happy Holidays!

Unity Farm Journal - Third Week of December 2015

December continues to be unseasonably warm.   The bees are very confused - breaking cluster and leaving their hives in search of nectar which is not available this time of year.   We’ve created feeding boards for each hive, covering a hardware cloth screen with a patty of sugar.     The bees will recover, but we’re worried about the fruit trees and bulbs, which seem to think it is Spring.   If full budding occurs now, the buds will die in January when the cold and snow return.

I just finished the Fall semester of my Umass Stockbridge Farming program, Organic Vegetable Production.   For my final paper, I created an organic treatment plan for Unity Farm in the framework of a local pest and disease primer for Sherborn, Massachusetts.  Here’s the full text of the paper 

The work on the mushroom area I described last week is now complete.   We have a comprehensive mushroom management plan, infrastructure, and processes.    Kathy and I have about 150 new logs to inoculate and the racks are ready to store them.

Last weekend we completed the last barn cleaning before winter, using our large shop vac and industrial strength Stihl Magnum blower to remove all the hay, dirt and dust that had accumulated over the year.   In theory, the animals will be spending time in the barn soon, when the first snows of winter fall.    The barn is so clean and orderly that a visitor suggested we be nominated for “Farm Beautiful” magazine (which does not exist).

The ground is still thawed and we finished all our 2015 planting - 10 new beds of American ginseng as well as 6 new Korean Bee Bee trees , a late summer bloomer to extend the nectar sources for the hives into the Fall.

As the end of the year approaches, I’m very happy with everything we’ve accomplished at Unity Farm this year.   There are a few small items we’ll need to improve our workflow.  It’s time to prepare the Christmas list, which I’ll share next week.

The December 2015 HIT Standards Committee Meeting

The December 2015 HIT Standards Committee focused on 3 key projects as we wrapped up our work for the year.

Cris Ross presented the work of the  Certified Technology Comparison Task Force .  The idea behind this work is simple.   Although certified technology includes a number of specific functions outlined in various regulations, it may or may not be fit for purpose by a given specialist or in a given clinical environment.  The group seeks to Identify the different health IT needs for providers across the adoption and implementation spectrum, with particular focus on providers with limited resources and/or lower adoption rates and publish tools to enable comparison of different applications.    Hearings from many stakeholder groups are planned.

Chris Chute and Floyd Eisenberg presented the recommendations of the Transitional Vocabulary Task Force.     Over the years, the HIT Standards Committee has learned that optionality is barrier to interoperability.   Offering a choice of different standards - an “or” - becomes an “and” for developers as well as creates data heterogeneity among clinicians using different vocabularies.     The task force recommends eliminating different vocabulary choices over time and implementing a single vocabulary per domain i.e. SNOMED-CT for all problems/diagnosis and LOINC for diagnostic study names.

Finally, Jon White presented an update on the Precision Medicine Task Force, identifying enabling standards.

Our next meeting on January 20 , 2016 will include all the members of the Policy Committee and Standards Committee.   It will be my last meeting and I will pass the baton to my successors Arien Malec and Lisa Gallagher.   I know the  HIT Standards Committee will be in good hands!

Unity Farm Journal - Second Week of December 2015

We’ve had a very warm December that has enabled us to do much more outdoor work than usual.    The effort of the past weekend  focused on refining our mushroom areas and permaculture plantings.  

Our end goal is 500 logs in production as follows

360 Shitake logs (4-8”) on 30 a-frames (pictured below)
 36 Shiitake logs (8-12”) on 12 4x4 bases
 24 Ganoderma Lucidum (Reishi) on the ground
 24 Nameko (Japanese mushroom) on the ground
 56 Oyster totems

We’ve decided to discontinue Lion’s Mane (poor yield) and retire those oyster logs that are no longer fruiting.    Last weekend we used the Terex front loader, forks, and our manure hauling trailer to move all the old logs into an a large pile adjacency to the orchard road where a commercial grinder can reduce them to wood chips for our trails.

Going forward we’ll focus on Shitake for 3 reasons
1.  Price point is nearly double of other types of mushrooms
2.  Shelf life is weeks, not days
3.  Fewer insect pests attack Shitake

Next weekend I'll be wrapping up my latest University of Massachusetts course, Organic Vegetable Production.   My final paper “Organic Pest and Disease Control in Sherborn, MA” covers all my experiences raising vegetables at Unity Farm, as well as the experience at surrounding farms - Sunshine, Sweet Meadow, and Dowse.    It will serve as a primer for agricultural practices at Unity for years to come.

As the holiday season approaches, we’re getting ready for the visit of family and friends.   As farmers, we’re very tolerant of our close partnership with the land and the animals we support.  We do not impose our lifestyle on any visitor.   If you want to shovel manure, you can, but there is no expectation that any visitor will follow our daily routines.   Tree house climbing, zip lining, hay hauling, forestry management and tractor driving are only for the willing!

It’s deer hunting season in Massachusetts (shotgun Nov. 30 – Dec. 12 and Primitive Firearms Dec. 14 – Dec. 31).   Local deer seem to know that Unity Farm is a vegan/vegetarian priority, so we have a deer freeway around our barnyard.   The alpaca/llama do not like deer (not clear why) and tend to trumpet in alarm when deer graze around our paddocks.    The Great Pyrenees always react to alpaca alarms with their own barking,  all night long.     You may have seen memes of the World’s Most Interesting Man - “I don’t always….”   Here’s our version:

We've posted no hunting signs every 50 feet around the perimeter of our 15 acres.   Given that rifle bullets can travel miles (assuming they miss their target and trees), we need to ensure our 150 animals are not harmed in any way during hunting season, so we have created a buffer zone using our property and surrounding properties.   We are careful to wear bright colors and avoid runs through the forest at dawn and dusk during hunting season.   I look forward to less 3am barking when the deer return to their usual range after hunting season!

The State of Information Security 2015

When I wrote about the most important healthcare IT stories of 2015 (such as ICD-10 and Meaningful Use), I did not include a discussion of Information Security.   That’s because security deserves its own post. Increasingly complex threats and an array of new security technology, policy, and education projects consumed us all in 2015.

Last week, I met with the Department of Justice Attorney General for National Security.  His message was clear.  With state-sponsored cyberterrorism and organized cybercrime on the rise, every internet connected device will eventually be compromised.  The only question is when.  By the way,  he works in a safe room without an internet connection.

2015 has been filled with denial of service attacks, hard to detect malware, and a skyrocketing number of personal internet connected devices at the same time that HIPAA enforcement has expanded.   The traffic on my guest networks from visitors using mobile devices has exceeded the traffic on the business network.   Meaningful Use requires us to share more information with more people for more purposes, but the HIPAA Omnibus Rule requires us not to lose a byte.

How did we survive the security challenges of 2015?

First, it is important to understand the threats and mitigate those vulnerabilities with the highest likelihood of being exploited and doing the most damage.    What is the #1 risk?

People.

The cartoon below illustrates the problem.

We spend millions on new technology, countless hours on policy writing, and engage all stakeholders to enhance their awareness.    Yet, we’re as vulnerable as our most gullible employee.

The scenarios I’ve seen in 2015 include:

*a clinician downloads an infected copy of Angry Birds to an android phone then logs into email.   The username and password is captured by a keystroke logger embedded in the running game software.   Massive spam is sent and the email domain is blocked by commercial internet providers

*A carefully crafted email encourages clinicians to login to Oracle financials to claim their yearly bonus.  A hospital’s Oracle Financials site is mimicked at a reasonable sounding URL.     Usernames and passwords are stolen and are used to change direct deposit information in the real Oracle Financials application.

*Social networks are used to infiltrate home computers and steal credentials.

Not only have we significantly increased our education efforts, but we’ve also put various filters on incoming email to scan every embedded URL and every attachment before delivering messages.   We’ve implemented various filters to prevent outgoing mail and internet traffic from exfiltrating sensitive data.  We require attestation that every device used by every person is encrypted and physically secured.

Our tools and dashboards identify variance in device, software, and people behavior.

Our security staff has been significantly increased.

Boards and senior executives are very sensitive to the reputational risks around security.   Security is supported by committees that include working groups, senior management compliance groups, and Board groups.

I’ve signed several vendor contracts in 2015 that include new liability and indemnification language protecting BIDMC against third party claims around breach issues.

The bottomline for 2015 - the threats increased and the technology, policy, and education efforts were redoubled.    Although ICD10 and Meaningful Use work may be diminished in 2016, security work is likely to increase.   As I’ve told the Board, security is a process, not a project.   You’ll get better and better but will never be done.

Unity Farm Journal - First Week of December 2015

Thanksgiving was a busy time at Unity Farm, turning our harvest into dinner for the family, “in-laws to be”, and all the animals.  

Life on the farm is one of constant learning - every day is filled with new experiences and challenges.  We somehow muddle our way through.

On Thanksgiving, one of our Americauna chickens, Amelia, was scared by a fox and hid under the shed in our pasture.   At times,  various creatures hide under the shed, but they always come out.   Two days later she was still under the shed and we had to take action.   The usual techniques - bamboo poles, a Stihl blower and 2x4s did not work.  We had no idea what to do, so we improvised.   We waited until after dark and when she was asleep we dug a trench under the shed and I delicately grasped her legs, protected her wings, and brought her back to the coop.   She ate and drank heartily.   At this point, she probably thinks the shed incident was just a dream.

We are a commercial kitchen and thus every year we have to sterilize our well to ensure good hygiene - no soil coliforms.    Our well is 300 feet deep and 6 inches in diameter.  Think of it as a 450 gallon column of water.     We add half a gallon of  8% sodium hypochlorite solution (germicidal bleach), then flush the resulting solution through all the pipes in the property.    This year, we did our sterilizing a week before our Thanksgiving guests arrived and all went well.   With all the guests in the house, water usage peaked and they drew down on the column of water much faster than Kathy and I would.    The end result was that more bleach passed faster  through the pipes than usual and the iron in the water precipitated turning our water orange/red.   We had no idea what to do so we improvised.   We connected a hose from the house to the well and ran it for 4 hours, passing it through a course filter along the way.      The end result was clear water with minimal chlorine smell.

The tractor parts we ordered for winter arrived this week - a pair of forklift forks and a 52” snowblower attachment for the Terex.   I’m very excited about sitting in the Telex, listening to 1970’s tunes, staying warm/dry, and moving 10 tons of snow per hour.

Last Fall we planted Ginseng - 5000 seeds and 500 roots on an east facing slope.   The deer ate many of our seedlings and it was not clear how many sprouted.  This year, we’re taking a more scientific approach.   Last weekend I built 10 raised beds laid out in a grid around the property - in shade, partial shade and partial sun.   In wet soil and moist soil.   In oak woodland and maple woodland.    I fenced each area using 5 foot welded wire fence on 6 foot T-posts.  By next May we’ll be able to count successful seedlings and determine what environment is best.

Now that every night is dipping below freezing, I covered every raised bed in the hoop house with row covers to enable growth even in the low 20’s.    At this point, our spinach, chard, lettuce, turnips and carrots are still doing well under row covers despite freezing nights.

Next weekend I will begin refining our Mushroom log collection based on what fruited this Fall and what did not.  I’ll retire some logs and layout new areas for freshly inoculated logs.   Our plan is to keep a steady state of 500 Shiitake logs, 24 Reishi mushroom logs, 24 Nameko mushroom logs, and 50 Oyster logs.    As a farm, we need consistent production that matches supply and demand.   After this weekend, our mushroom areas will be optimal.