Building Unity Sanctuary - Second Week of February 2017

I have been traveling in Japan and New Zealand this week so Kathy had to manage the sanctuary and farm.

The major challenge has been the snow, ice, and cold.   While I’ve been away, 18 inches of snow have fallen, making sanctuary operations more challenging than usual.

Pippin, our 30 year old Welsh pony is recovering nicely after his tooth surgery.   He stopped eating and lost weight rapidly because it hurt so much to chew.   The vet sedated him and removed the offending tooth by breaking it into 3 pieces.  Antibiotics cleared an underlying gum infection and his appetite returned.   We’ve enhanced his diet with timothy hay pellets, a mixture of high fiber grains for senior horses, and grass hay.  It’s great to see him healthy and happy again.

The other horses, Amber the Arabian mare, and Sweetie, the Welsh pony, continue to thrive and the herd gets along well.    We’ve moved them into the barn during the storms to keep them warm and and dry.

We learned this week that goats do not like to eat off the ground.   We’ve been creating piles of timothy hay for them and although they’ve eaten them, they left a lot behind.   Kathy ordered a wall mounted goat feeder for me to install when I return.

In my absence Kathy has organized classes at the Sanctuary and juggled interior painting/repair work around the classes.   She’s also designed a second run in for the goat paddock so that we can house rescue donkeys in the same space as the goats.   Donkeys can serve as a livestock guardian animals, keeping the goats safe from coyotes, bobcats, and other predators.   There is a wonderful donkey rescue organization in New England that we’ll be working with.

I’ve begun conversations with other non-profits in our local community about how best to collaborate.   We can share our sanctuary space for educational events, connect our trails to other community walking trails, offer our support to other local causes.  Since our goal is to use the Unity Sanctuary as a public gathering space for the benefit and education of the community, it’s important that we identify all the possibilities and present them to the Sanctuary board for discussion.

Next week, a Welsh pony, Millie, arrives as well as Penny the yorkshire pig.   Our paddocks and barns are ready to receive them.    Our daily routines of alpaca care, pig care, horse care, poultry care, and dog care are now optimized, so we are efficient at meeting everyone’s needs.

I return to Boston on Friday night and will spend the weekend doing all the maintenance, repair, and building tasks I missed during the week.   HIMSS (a major national IT conference) begins next weekend, so February is a tricky month to balance job, farm, sanctuary, live and travel.   So far, so good.

Dispatch from Japan and New Zealand

This week I’ve taken vacation time to help my colleagues in Japan and New Zealand with national IT planning.    As I often say, the healthcare IT challenges are the same all over the world, but the cultural context is different.

In Japan, I spent 2 days in Tokyo and 1 day in Kyoto, lecturing, meeting, and listening to stakeholders.   There is a great desire to share data for care coordination and clinical trials/clinical research.   Telemedicine/telehealth is increasingly important in an aging Japanese society that has increasing healthcare needs but a limited number of caregivers and few opportunities to increase healthcare budgets.  Here are a few of the current issues we discussed:

1.  Some early data exchange pilots in Japan have used a healthcare specific XML form called Medical Markup Language (MML).  Others have used IHE standards such as XDS.b . There is not universal adoption of a specific content standard among the majority of Japanese EHRs, many of which are custom created for each hospital.    I recommended that Japan adopt CCDA as a summary content standard and FHIR as a query/response standard.

2.  There is limited adoption of controlled vocabularies.   SNOMED-CT, LOINC, and ICD-10 are used in pockets, but are not mandated by national or local regulations.     There is some early work being done on OpenEHR and the use of schemas/archtetypes to represent data in a semantically interoperable way.    I recommended the universal adoption of a single controlled vocabulary for each clinical area - SNOMED-CT for problems, LOINC for Labs and ICD-10 for diagnoses.

3.  There is no standard means to send/route data across the country.   Japanese privacy laws are not “internet friendly” and require the use of VPNs, leased lines, dedicated fiber etc.     I suggested that https over REST is good enough.

4.  There are not significant incentives to adopt healthcare information technology.   Although I did not encourage a Meaningful Use program for Japan, I did highlight the notion in HITECH of creating carrots and sticks for achieving specific policy goals.

5.  Prime Minister Abe wants more entrepreneurial Japanese, but that is challenging  in a country where the failure of a startup is considered a reputational risk.   Building a startup culture requires the creation of a "safe zone" where risk and rapid failure are tolerated.

In New Zealand, I met with government ministers, academia, industry, providers, and patients to describe my international experiences with healthcare IT innovation and how lessons learned might apply to New Zealand efforts.  There is a remarkable alignment of government sponsorship, technology expertise, and an urgency to change in New Zealand.   The desire to share data for quality measurement, care management, and enhancing social services extends to the highest levels of government.    With 5 million people, a national healthcare identifier, well organized district health boards, uniform privacy laws, and a robust planning process, New Zealand truly is the perfect storm for healthcare IT innovation.    Here’s my sense of their short term priorities

1.  Complete their current multi-stakeholder engagement process to define priorities for the next 5 years

2.  Determine the range of privacy preferences in New Zealand society then implement the technology and policies needed respect those preferences for multiple uses of data

3.  Based on their high priority business cases, develop appropriate tools to push, pull and view data among stakeholders

4.  Encourage an ecosystem of innovation so that startups can build products which plug into existing enterprise software

5.  Focus on the needs of patients and families by ensuring they collaborate in producing and managing their healthcare data.

Just as I’ve done with the England, Scotland, Canada,  Nordic countries, and China, I wrote briefing/position papers for leaders in Japan and New Zealand before I left.  

I’ve said previously that my goal in life is to make a difference.  If I can be a catalyst around the world to accelerate healthcare IT best practices, mitigate risk, and minimize repeated mistakes, I will have achieved my goals.

Building Unity Farm Sanctuary - First Week of February 2017

Running an animal sanctuary requires constant attention to the care and well being of all the creatures living there.   This week, Pippin, our 30 year old Welsh pony stopped eating hay and required urgent intervention.    He did not appear to be suffering from colic.  He ate treats and sweet grain, which we minimize because of his Cushing’s disease.   We knew he had numerous dental issues but to evaluate the situation he needed to be sedated.   The vet figured out he had a loose tooth that prevented him from chewing grasses.    She removed the tooth, placed him on antibiotic coverage and gave us two nutritional supplements to help him get back on his regular diet.    As an older, thin pony, he lacks reserve so we’re very focused on increasing his caloric intake, maximizing his weight gain over his Cushing’s treatment.   I’ll report back on his progress over the next week.

Community events at the sanctuary have begun with yoga classes and meditation classes meeting in the Unity Meeting House.   All the floors in the building have been freshly refinished and the odor of polyurethane has faded.   Daily fresh air ventilation and a bit of incense has made the building very pleasant.  

Only two rooms in the building had carpeting and we’ve replaced all with pre-finished wood in keeping with the 1830’s look of the original building.    Kathy will hold an art retreat in the newly finished third floor space next weekend

We’ve also continued repainting the entire inside of the building using beiges and blues consistent with the older finishes.   All the remaining wallpaper from the 1980’s and 1990’s will soon be replaced with the vintage paint colors.

We’ve carefully inspected all the exterior wood surfaces and we’re replacing anything rotted/decaying with azek, especially anything at ground level.     The work on the wiring, plumbing, telecom, audio, and security will be done by next week.

Over the past 50 years, workman have left pieces of retired heating ducts, electrical boxes, and lumber in the crawlspace below the house.    Using my toughened mountain climbing clothes, I’ve crawled through every square foot under the house and bagged up all the debris.   Another few hours of work next weekend and the entire crawlspace will be as it was when the house was first built.

Hopefully our efforts in March will focus on the animal housing and paddock areas - we’re hoping for cool, dry weather to make it possible for us to finish clearing fallen logs, rocks, and brush, enabling us to begin the new fencing  which will surround the new rescue areas.

This week, we built a new “toy” for the goats - a 4x4 foot platform, 18 inches high.   They play king of the mountain, climbing on the platform and knocking each other off until only one is left.   Typically Napoleon wins the battles.   He’ll even carry a pine branch onto the platform, so he can enjoy a snack while surveying his domain.

Next week I’ll be in Japan lecturing,  meeting with government/industry/academia, and spending time with old friends.   Kathy will be running the farm and sanctuary operations with the help of our growing team of volunteers, interns and helpers.    I’ll be in constant touch, ensuring all is well.

We Must Think and Act as One Planet

Over the past few days, several journalists have asked me to comment about travel bans, immigration policy changes, and trends in isolationism.

My opinions are my own and do not reflect any official position from my employer or my academic affiliation.

Here are my observations

1.  Information Technology is global.   We hire the best talent regardless of nationality, gender identity, sexual orientation, religion, or race/ethnicity.   Having worked in 75+ countries in my adult life, I can say that innovation crosses all boundaries and cultures.   It’s just as likely that next big breakthrough will come from EMEA as it is from APAC.  I cannot imagine restricting the flow of collaboration among academics and technology professionals from any country.

2.  I was born in 1962.   My grandmother described that for much of her life drinking fountains were separated based on race.  Other relatives have talked to me about the controversy of electing John F. Kennedy, a catholic, as president.   My mother was one of the first female law school graduates from her school.  As a society, we’re moving past issues of classifying people and limiting their roles.  2017 is not  a time to divide the world into “us” and “them”

3.  In my youth, Fedex (overnight shipping) did not exist.   Software could not be downloaded.   Communication was by paper letter.   At this point in history there are no barriers to instant communication and information sharing around the world from every person and culture to every other person and culture.

4.  Many of the skills that have made me successful in life are now completely obsolete.   I could type very accurately and produce flawless sheets of text on my Smith Corona.   I could search the card catalog at public libraries and read literature very fast to find salient facts and quotes.   I could memorize large amounts of information - a kind of human Hadoop.    Today, no one needs such skills.   Google, Amazon, Facebook, Twitter, and Netflix skills are much more valuable.   Automation has completely changed the job market.   Immigrants are not taking away jobs, but the evolution of work itself has led to the “rust belt” and the closing of US factories.    It’s naive to believe that building a wall or restricting the flow of people will bring back the jobs at the “plant” of the 1970s to middle America.

5.   I am a first generation American.  My mother was born in Latvia.   My father’s family is from Prague.   What makes our family, which immigrated in the 1950s any different from a family trying to immigrate in 2017?   An immigrant is an immigrant regardless of the country of origin or time period.   If we blocked Steve Jobs’ family from immigrating out of Syria, Apple would not exist.   Is that what we want?

The bottomline is that we’re a global economy, dependent on each other for resources, ideas, and innovation.    Throughout the world we’re seeing globalism being abandoned in favor of regionalism.    Many believe that by dividing the world into the haves and have nots, we’ll improve the situation from some while diminishing the situation of others.   Some will win and some will lose.   This is very short sighted since we’re only one finite planet with finite resources.   We need to think as one planet, one people, and one species.   Rhetoric, demagoguery and populist rabble rousing may seem appealing in the short term but they do not address the critical problems we face today - climate chance, environmental destruction, and a population that exceeds the carrying capacity of the available resources.

My role in 2017 is to serve the world around us, embracing all people, and openly sharing ideas.   I will not criticize the officials in the current US administration but I will criticize their ideas.     The era of US leadership is fast coming to an end and building walls will only accelerate our demise.   I look forward to a future when we all recognize that our work is the successful future of a unified human species, not a return to a past that can never exist again.

Building Unity Farm Sanctuary - Fourth Week of January 2017

The Board of Directors of Unity Farm Sanctuary held its first meeting at the Unity Meeting House the 1830’s building on the sanctuary property.    The “board room” is the original dining room, made from American Chestnut, which no longer grows in New England due to the chestnut blight of the early 1900’s.   Since the floor is nearly 200 years old, not a single board is square and a marble rolls spontaneously across the floor.

The Board agenda including a walking tour of the entire sanctuary property and a review of all existing survey maps, such as the one below which identifies structures, wetlands, and  topography.

We reviewed several important documents
1.  the IRS Form 1023/supplement requesting charitable status for Unity Farm Sanctuary
2.  an omnibus insurance package including structures, umbrella liability, animal coverage, employee coverage, and even cyber-liability coverage (since we may keep donor data)
3.  a financial sustainability model
4.  a review of infrastructure improvements done to date
5.  a project plan for 2017

The board approved the IRS Form and insurance package.   Yesterday the IRS submission was completed and the journey to non-profit charity began.   The insurance becomes effective this week.

The board also heard about the pending sanctuary animal placement requests.   We explained that poultry, alpaca/llama, and goats are relatively scalable - we can take on additional animals without huge effort.

Horses and pigs are hard.   Horses require a significant degree of daily care and pigs need complex socialization to create a tight knit peaceful community.    We will be adding one additional Welsh pony and one additional pig in February.  Other horse/pig additions will await the construction of new animal care areas shown in the map above.   The existing creatures are happy and healthy.   Here's a few pictures from this week.

Furnishing the sanctuary buildings has been a labor of love.   Kathy has used Facebook and other social media resources to identify people in the community who are moving or downsizing.  We then visited them to explore their attics, basements, and garages.   We’ve purchased items from the 1800’s that could have been in the Unity Meeting House when it was first built.  We’ve kept costs low so that there is no fear of loss/destruction of these furnishings, since the building will be a public space.   The dining room picture above illustrates the kind of pieces the public will use when using the property for events, educational activities, and volunteer opportunities.   We’ve really worked hard to think about high traffic uses, children, and plenty of farm messiness.   The only objects we’re adding to the sanctuary operation are low maintenance, low risk, low worry.

We’re making rapid progress on infrastructure, operations, legal, financial, and governance matters.   Every week brings new possibilities, challenges, and adventure.

What is Care Management?

I recently joined the advisory board of Arcadia Healthcare Solutions, a leading provider of analytics, decision support, and workflow enhancement services.   At my first advisory board meeting there was a rich debate about the marketplace for care management and population health tools.   I’ve spent years studying such solutions at HIMSS and found most of the products are “compiled in Powerpoint”, which is a very agile programming language, since it’s so easy to change…

At BIDMC, we think of care management as two things
*identifying a cohort of patients based on analysis of financial and clinical data
*creating and tracking an action plan for that cohort

We built those core components into our self developed EHR some years ago.   The tools are in very active use to reduce readmissions and improve quality using disease specific protocols.

Other care management services are very important, but we are happy to delegate development of such tools to third party cloud and mobile providers.  Such items include customer relationship management applications supporting case managers, patient facing health coaching, secure patient/family/caregiver groupware, self management resources, and chat/tele-visits.

In my experience, the hardest aspect of care management is unifying financial and clinical data from multiple heterogenous sources, linking the right patient records together, and curating the data to improve data quality.   Once such a foundation is available, then tools for analytics and data visualization can be added on top.  

Most clinicians know they need care management and population health tools, but they are not sure what they need, what questions to ask, and what techniques should be used to turn the data into wisdom, such as risk adjustment.

The Trump administration has signaled its desire to reform Medicare.   Tom Price, nominee for HHS Secretary, has noted that the EHRs are burdensome and quality measures are often misaligned with practice workflows.  Medicaid is likely to be more tightly coupled with local care delivery strategies at the state level.

Despite all these changes, the notion of paying for quality and outcomes instead of quantity will move forward.   The only way to succeed in a value-based purchasing world is to embrace care management techniques that can keep patients healthy in their homes, reducing total medical expense, improving wellness, and enhancing patient satisfaction.  

My advice to Arcadia and to the industry
1.  “it’s the data”,  not a killer mobile app that needs to be the top 2017 priority.   Once the longitudinal community-wide clinical and financial data is collected and cleansed, the rest will follow.    Arcadia has unique expertise in data science, as demonstrated by its high KLAS ratings.
2.  Don’t introduce too many different disparate innovations into clinician workflows simultaneously.  
3.  Spread the care management activity across teams of staff, each practicing at the top of their license - doctors, nurses, case managers, pharmacists, and family caregivers.   Minimize data entry burden.
4.  Partner with other companies and organizations which offer complementary mobile application services
5.  Become a value-added contributor to the EHR ecosystem, not a competitor to EHR vendors.   Although EHR vendors will offer basic population health within their products, no single EHR vendor can combine data across all the sites of care visited by a patient, so third party care management tools will always be important.

I hope this provides a logical roadmap for the care management work ahead and enables you to validate that the organizations promising care management products and services can really deliver them.

Building Unity Farm Sanctuary - Third Week of January 2017

This weekend we’ll run our first Sanctuary board meeting, providing our 7 member board with an overview of

Animals and activities
Financial
Legal
Infrastructure
Projects

Our strategic goals in 2017 are

Develop internship program
Develop educational programs
Develop additional funding possibilities
Develop standard intake process
Develop trail plan in collaboration with the Sherborn Rural Land Trust

Here’s a brief update about what we’ll tell them

In February we’ll take on another horse (Millie, a 20 year old Welsh Pony) and another pig (Penny, the 1 year old Yorkshire).    We’re making modifications to the existing layout to accommodate them.   Likely Millie will run with Sweetie, leaving Amber and Pippin together since they have bonded.   We’re enhancing the outdoor run ins and modifying the barn traffic flow so that 4 animals can easily come and go through the main barn entrance.   We’ve taken on two Bielefelder roosters and they are now integrated into the rest of the flock.    We’ve received requests to take on a few more horses and pigs, which we do not have the space to add over winter.   In the Spring we’ll finish another acre of paddocks/run ins, and hopefully we’ll have a standard intake process by then so the board can help decide which animals we take on permanently and which we help in the short term.

The initial sanctuary budgets are ready for board review and our plan for long term sustainability will be presented.

The 501c(3) IRS filing for the sanctuary has been done.

Last week we refinished all the wood floors and removed about a mile of unused legacy wiring that had powered a 1990’s in building Hi-Fi and video distribution system.   It seems that every property we take on has a endless phone wiring from the 1980’s, cable TV from the 1990’s and sound systems from the early 2000’s.    Now that it has all been pulled we have an electronic greenfield in the Sanctuary, enabling us to add educational technologies as needed.    We continue to improve the barns, fences, paddocks, and run ins with additional hardware and equipment to make daily animal care easier.

This week the dead trees threatening paddocks and buildings come down and we’ll grind them up to cover the paths we’re creating through the property.

It’s exciting to see it all take shape.   Every night we’re at the Sanctuary doing projects.   Every weekend we’re there when we’re not doing direct animal care.   Once the floors are done, the patching and painting of interior walls begins.   In the spring we’ll move to the outside, replacing roof shingles and repairing rot/woodpecker damage.    The big project will be redoing the barn roof, which is sagging.

February is generally the snowiest month in New England, so our project work will get harder.   The Terex PT 30 front loader will work overtime keeping the paddocks, roads, and trails clean.  

So far, so good.  No major surprises in the building of the Sanctuary and the adoption of animals while we’re building.