Wednesday, April 26, 2017

The Dark Side of E-commerce

As I mentioned in a recent post, Amazon has focused on the convenience of the customer instead of the convenience of their business.   Yesterday’s New York Times highlighted the trend for the hotel industry to do the same.

In my post, I lamented that some industries including old school industrial companies and healthcare have not widely adopted customer focused technologies.    To their credit, Marvin Windows followed up with me and promised to accelerate their automation efforts.    I was impressed.

However, all is not completely rosy in the transformation from brick and mortar to e-commerce.

In an effort to reduce costs and presumably increase the value of an Amazon Prime membership, Amazon has moved away from traditional delivery carriers - UPS, Fedex, USPS etc. deploying  its own delivery service.   The Amazon cargo vans seem to be scheduled such that there is no consistent driver who knows the neighborhood, the people, and  property specific delivery details.

Many of these drivers have no experience delivering to rural areas.      Many are terrified by the chickens, guinea fowl,  and ducks wandering around Unity Farm.   I can tell you that  poultry are not a threat to delivery people. Maybe they’ve been watching too much Monty Python.

The drivers have decided that throwing packages out the window and speeding away is the best way to avoid contact with the animals.   We’ve had packages thrown at the barn, tossed into bushes, submerged into puddles, dropped out of windows, and left in the middle of the driveway.      I can only guess they used this as a training video.

We’ve had so much damage that we’ve had to make a decision
1.   Stop ordering from Amazon entirely
2.   Open a post office box and hope that Amazon will deliver items there unharmed
3.   Change our shipping address to the Unity Farm Sanctuary where horses and goats live in paddocks and the most threatening free range animal is a squirrel.

We’ve decided on #3, giving up on Amazon’s ability to deliver to a rural setting because it has built an army of inexperienced delivery people.

The recent United Airlines passenger dragging scandal illustrates what happens when corporations emphasize growth and profitability over long term customer relationship management.     Maybe as a society we have become desensitized to the gradual degradation of relationships with those who provide us services and we’re unwilling to pay for higher quality experiences.   As we continue to accept poorer and poorer service, we’re likely to see income disparities increase with inexperienced service people paid less and the companies they work for earning more.  Is it any wonder that the middle class continues to shrink?

I would be willing to pay a bit more to have a consistent delivery person who understands my neighborhood.   E-commerce is great but only when the last mile is representative of the rest of a superlative supply chain operation.   At present, I would call Amazon’s move to direct delivery a failed experiment as it relates to our needs, and I will have to work around it.

Thursday, April 6, 2017

Building Unity Farm Sanctuary - First Week of April 2017

In North America, Easter and Thanksgiving are traditionally associated with eating ham and turkey.     You can imagine that a vegan sanctuary is very popular with creatures who want want to avoid being eaten.

This week, we had the great turkey chautauqua .   Every wild turkey in the local forests assembled at Unity Farm Sanctuary for an afternoon of companionship, dancing and gentle conversation.    To put this photo in context, it’s taken from the sanctuary loft - about a football field away from the turkeys.  There are 17 turkeys in just this view.  Yes, the Tom turkey in the middle of the photograph was about as big as a buffalo.  Several guineas joined the party. Amazing

Local press covered the sanctuary activities this week and including some great pictures of the sanctuary animals.

I’ve built many things for Unity Farm and Sanctuary, but never considered building an ark until this week.    The snow has melted at the same time we’ve had 10 inches of rain.   The ducks and geese are swimming in the pig paddocks.  In the female alpaca paddock, water is over a foot deep.   The trails are a sea of mud.   It’s definitely a challenging time to be a farmer.

All the animals are smart enough to seek shelter from the rain and wind.   Even Palmer the turkey has begun to roost with the chickens so he stays warm and dry.

Whenever possible, the humans are attending to indoor tasks.   For example, suppose you want to cook the perfect Unity Farm eggs for Easter.  (vegetarian, not vegan).  Here’s a video about how to do it (note the Unity Farm packaging!)  

We finished the rewiring of the dining room  this week, correcting the sins of the past that occurred when old wiring and new wiring were grafted together in the 1990s.    Now, everything works perfectly.

We finished the spring planting of lettuce, carrots, peas, chard, beets, spinach and basil.   Our organic certification renewal is next month and we’re continuing our pesticide/herbicide free farming methods.

Finally, we began the planning for the trails that will connect the sanctuary with the rural land trust next door.   Their 30 acres and our 30 acres will combine to create an wonderful public walking resource.   I’ll definitely get my exercise this summer building another few miles of trails and bridges.    When we’re done, there will be public entrances on Green Street, Unity Lane and Zion Lane in Sherborn.

Wednesday, April 5, 2017

A Cautionary Tale for Healthcare

During my CIO career, I’ve worked on a few Harvard Business School case studies and I’ve had the “joy” of presenting my failures to Harvard Business school students for over a decade.

I enjoy telling stories and inevitably the cases I teach are about turning lemons into lemonade.

In this post, I’d like to tell a story about a recent experience with Marvin Windows and lessons learned that apply to healthcare.   I know that sounds odd, but hear me out.

At Unity Farm and Sanctuary I’m the proud owner of about 100 Marvin windows from the 1990’s.   All are still functional but incorporate nylon parts that eventually dissolve in sunlight.   I needed to replace the nylon pins that hold the screens in place.

I did what anyone would do.   I searched the internet for Marvin Top Rail Screen Pin, expecting to find the parts available on Amazon or a Marvin website.   No such luck.   Plenty of “plunger pins” but no top rail pins.  I did find an unindexed PDF of a Marvin catalog .   On page 43, I found "Top Rail Screen Pin M120 11867852”.   I had a part number so ordering it should be easy, right?

I went to the Marvin website looking for a part lookup function, an ordering function, or a customer service app.   No such luck.  I did find a corporate 1-800 number on the Contact Us page.

After calling that number I was redirected to  the web page of a distributor, since Marvin Windows will not sell anything to anyone directly.

Two days after emailing the distributor, I received an email back from a very kind and helpful person explaining that I had checked the wrong box on the distributor’s webpage - the part number I was asking about is from the Marvin product line and I had checked the Marvin Integrity product line.

I explained the part number is the part number and I have no idea what product lines Marvin offers.

She noted that the part was available but the distributor sells nothing to no one directly.    I will have to find a local retailer and begin the entire process again.    She was incredibly service oriented and when I asked, she agreed to find a retailer for me and tell them what part number to order.

Two days later, I received an email from a retailer 50 miles away noting that they could order the parts for me.   I asked the cost and they said .25 each.    Given that the process of getting a window part from Marvin is highly convoluted, I ordered 50 - a lifetime supply for the grand sum $12.50.   I asked when the parts would arrive.    The answer is unknowable since the retailer contacts the distributor who contacts the manufacturer and none of the above have customer accessible supply chain tracking or logistics information systems.

Two weeks later I emailed again and was told the parts would arrive 50 miles away in another week.

A week passed and I received a call from an incredibly service oriented person at the retailer who told me my parts had arrived (they weigh one ounce and fit in a standard letter sized envelope).   I asked if she could mail them to me and she responded that Marvin retailers cannot mail anything to anyone.    They tried it once a few years ago and since they don’t know how much postage it costs to mail a one ounce letter, the package would likely be returned undeliverable after a few weeks.   Best not to risk using shipping services and instead, drive 1.5 hours to pick them up, sometime 8a-5p Monday through Friday.

Of course, I have a day job so that would mean taking time off work.    I arranged to do conference calls during the 1.5 hour drive.    I received my one ounce of parts for $12.50 one month after my search began.   They fit my window screens perfectly.  Victory!

One the same day I picked up the screen parts, I needed a very obscure electrical wall plate to cover an old electrical box with a deactivated switch.    I needed half decora/half blank.   I could not imagine such a part was ever made.    30 seconds after searching Amazon, I found it, clicked once and 12 hours later found it on my doorstep without lifting a finger (or paying shipping).

The purpose of telling you this story is that Marvin Windows senior leadership (and the Board) must be using  Cobol-based mainframes to manage the company when they're not taking calls on their flip phones.   It’s clear they’ve been asleep since 1985.    When it comes time to replace the windows in my buildings,  I would never consider Marvin Windows products, since it clear they care more about preserving an ancient business model and less about their customers modern expectations and experiences.    Such companies will wither and be replaced by an “Uber equivalent” for windows.

But wait, I’m living in the glass house of healthcare and throwing stones.   Just how easy is it to make an appointment with your doctor, seek real time telemedicine/telehealth advice, or get access to a “care traffic control” logistics application that shows your progress against a care plan?  In 2017, healthcare is still largely following the Marvin Windows approach of phone, fax, email, smoke signals and morse code.

The lesson learned is that in the near future, healthcare organizations that offer an Amazon approach will displace this which do not.   That’s why BIDMC has focused on 5 pillars to guide IT projects in 2016 and 2017 - social networking communication tools, mobile enablement, care management analytics and cloud services.   Every month we’re launching new functionality that gets us closer to the Amazon experience with such apps as BIDMC@Home (internet of things/telemedicine), OpenNotes, and Alexa ambient listening services.   In two weeks, our entire dataset will be moved to the Amazon data lake with appropriate privacy agreements and security protections so we can take advantage of cloud hosted machine learning and image recognition services.     By 2018, we’ll be much less Marvin Windows and much more Amazon.

I do not know the window business and maybe there is something about it that supports old business models while the rest of the world  innovates.   However, I do know healthcare, and we need to embrace the same kind of consumer echnology focus as every other industry.   If we don’t, our bricks and mortar buildings will go the way of Sears, JC Penney, and Macy’s  .

Thursday, March 30, 2017

Building Unity Farm Sanctuary - Fifth Week of March 2017

We continue to refine the sanctuary buildings, prepare the new animal care areas, and keep our creatures healthy.

Sweetie, our 18 year old Welsh Pony developed a sore on her right lip.    Using my human medicine training I inspected it for abscess formation and drained it, while also applying local antibiotics.   It did not heal this week, so we asked the horse vet to take a look.   It turns out that when horses have tooth abscesses in the lower jaw, they develop drainage tracts in their lips.    Tooth abscesses in the upper jaw drain into the sinuses and out the nose.    She’s now on systemic antibiotics and we may pull a tooth next week

My work on the sanctuary's 50 windows and screens, restoring all missing parts, took its toll on my hands.   These are supposed to be surgeon’s hands, not filled with cracks and calluses!   I guess I’m destined to have farmer’s hands.   We had snow, rain, and strong wind this week without a single window/screen issue.

As we go through our checklist of finishing touches on the sanctuary building, we’re fast approaching completion.  The last of the replacement carpet, the last of the furniture (library chairs) and the fire alarm system went in this week.

We added bird feeders to support the local fauna, both nut and seed eating types.

We’ve finished the tree work in preparation for the new paddocks as well as trimmed the branches that could injure animals in a windstorm.

As the weather warms, the trail work begins and we’ll walk the property next weekend with leaders from the Sherborn Rural Land Trust, figuring out how to connect existing public property with the sanctuary to create a network of local trails.

We’re hard at work on new paddock designs, ensuring they support a diversity of animals, offer a logical workflow, and abide by all local regulations.  In theory, paddock fencing installation should begin in mid-April.     Here’s a view of the new areas which maximize animal use of sanctuary land.

This weekend we’ll be training volunteers, rewiring the dining room (that story will be told next week), and  hosting a yoga retreat.   With good weather planned, we’ll have plenty of animal time, grooming, exercising, and feeding our charges.

Wednesday, March 29, 2017

Early Experiences with Ambient Listening Devices (Alexa and Google Home)

BIDMC has a long tradition of testing speculative technologies with the notion that breakthroughs often require tolerance for failure.   For example, we’ve embraced blockchain in healthcare because we believe public ledgers have promise to unify medical records across institutions.

Over the past few months, we’ve developed healthcare applications for Alexa, Amazon’s ambient listening device that combines natural language processing and easy to use application program interfaces.    We have also tried Google Home.

Here’s our experience thus far.

1.  We’ve used Alexa in a pilot inpatient setting (not real patients).   Here are the questions/use cases we’ve implemented with back end interaction to our operational systems.

Alexa, ask BIDMC

What’s my room number
Who’s on my care team or List my care team
What is my diet or What can I eat
Call a nurse   or   I need a nurse  or Send in a nurse
Give me some inspiration  or Inspire me
I need spiritual care    or    Request spiritual care
I need a social worker   or   Request social work
What's my care plan for today  or What are my planned activities for today
Ok, thanks    or   Stop   or   You can stop

2.  Sentiment analysis

What is sentiment analysis - the process of computationally identifying and categorizing opinions expressed, especially in order to determine whether the author’s attitude towards a particular topic, product, etc., is positive, negative, or neutral.

We are beginning to use sentiment analysis on social media mentions of BIDMC. We have done a pilot to spot out BIDMC mentions on Twitter and with Google democratizing their sentiment analysis API at the conference a few weeks ago we are working on ingesting the feeds. Conceptually the same approaches can work on Alexa to analyze mood and urgency.   We will try it in an attempt to communicate emotion as well as text in the ambient listening workflow.

3.  HIPAA Compliance

Alexa and Google Home are not "HIPAA compliant" i.e. neither Amazon nor Google will sign business associate agreements for ambient listening technologies.  Both organizations are working on policies and controls that would enable them to sign such agreements for their speech driven products. Once we sign BAAs, we’ll explore use cases like a surgeon asking for patient data without needing a browser/keypad.

In the meantime, we’re not using patient identified data in ambient listening applications.   The questions above are anonymous -  the HIPAA 18 identifiers (i.e. names, social security numbers, addresses etc.) are not included in the data stream.

We're exploring a few other use cases outside of HIPAA controls, such as querying knowledge bases - commonly asked questions delivered via an ambient listening infrastructure.

4.  Accuracy
We have not had any unexpected misunderstandings when parsing spoken language.  There is a famous You Tube video illustrating a 3 year asking for hickory dickory dock and getting a pornographic response.    The only issue we’ve had is that Alexa can be sensitive to ambient voices, causing it to respond to an unasked question.

5.  Expanding the use cases to the outpatient scheduling domain

Amazon has offered Lex as a service that can be used to embed natural language processing in mobile apps that could be used for patient self scheduling.  We hope to support a use case of patients in their homes requesting appointment/referrals and interacting entirely with Alexa instead of having to place a phone call or visit a website.

Thus far, we’ve been very impressed with the capabilities of these conversational services.   The web was our focus 1996-2012.   Mobile has been our focus 2012 to the present, what I call the post-web era.  I can imagine that by 2018 we’ll enter the post-mobile era and have conversational interfaces based on ambient listening devices in patient and provider locations.

Thursday, March 23, 2017

Building Unity Farm Sanctuary - Fourth Week of March 2017

It’s officially Spring and although the weather is cold and snowy, the anticipation of warmer weather means that Unity Farm Sanctuary is more active than ever.

This week, a local young woman purchased our goose eggs and made traditional Ukrainian Pysanky Easter eggs.   We were impressed.

The owners of Penny Blossom, the Yorkshire pig living at the sanctuary for a year, brought us empty wire cable spools.    The goats are jumping from spool to spool, having a great time.

This week, we finished creating the last bedroom at the Sanctuary using a 1760’s bed we found in Plymouth.   It was not designed to use a mattress and has spools for ropes to hold straw.    Each night you tighten your ropes so you “sleep tight”.   That’s actually where the term comes from.  Sanctuary guests would likely have trouble maintaining the ropes and straw, so I created a bed frame.

The most important development this week is that we finished clearing the land between the farm and sanctuary in preparation of new animal paddocks for rescue operations.   Here’s a view of the freshly cleared land with a herd of deer running across it.   In April we’ll install 1700 feet of fencing to create 4 paddocks, each with its own 24 foot mini-barn.   We’ve been collecting pottery for a charity sale in the Spring.   My daughter joking refers to this area of the property as the “pot farm”.

On the south side of the sanctuary, there are 27 acres of rural land trust open space.   We’re creating trails that connect the open space with our land, eventually resulting in 5 miles of walkable trails over the combined land.   We hope to expand our bee hives to the meadow in the open space.

I’ve designed paths that follow the natural topography of the land and while exploring the property, I found long abandoned bee hives.   My wife asked me to remove them to avoid any potential spread of spores from old American foul brood, but  irst I have to talk to the mouse who is renting the old hive!

Over the next few years, we’ll reintegrate the Sherborn land that was originally laid out in the Revolutionary war.  If we’re lucky, the assembly of land we own, land trust, wetlands, and  farm designated land will result in  200 acres of contiguous agricultural land for the public.

This weekend, we’ll finish the the repair of the sanctuary building, fixing all the windows and screens in the original 1830's building and the newer construction areas.  I’ve purchased enough spare parts to restore 50 windows/screens  to their original condition.   I suspect that by the end of the weekend my hands will be a bit strained!

Wednesday, March 22, 2017

Embracing Innovation

I’ve written several posts over the past two years about the need for innovation in healthcare IT - deploying self-developed apps, leveraging third party cloud hosted functions, and embracing the internet of things.

I’ve previously discussed establishing a center for innovation.   In preparation,   I’ve worked on innovative projects in industry accelerators, academic collaborations, and government sponsored hack-a-thons.

What has worked?

1. I’ve learned that it is very important to make innovation a part of the day to day work inside an organization.    Creating change externally and then trying to graft it internally results in a disconnect between research and operations.   At BIDMC, we’ve created a meritocracy in which those have competitively illustrated out of the box thinking are given reserved time each week to focus on highly speculative areas of innovation.    The project started as ExploreIT and is now being formalized as the Center for Information Technology Exploration in Health Care.

2.  It’s important to leverage commercial tools and services rather than trying to reinvent technologies that are becoming commodities.   Agile innovation is the unique combination of existing ideas and is more about creating the plumbing between components to support a workflow than doing large amounts of raw coding.

3.  Just as with venture-funded startup companies, in a cohort of 10 projects,  6 will fail, 2 will limp along and 2 will be winners.    We must create a safe environment where failure is permitted and exploration is its own reward.   We’ll move projects from pilot to production only when they are proven to be ready for prime time

4.  We’ll avoid being distracted by magical technologies at the peak of the hype curve (see below).  Instead, we’ll choose the appropriate technologies that satisfy business owner requirements based on experience in industries outside of healthcare.

5.  At times we’ll be early adopters and will be the first to test a new idea.   At other times we’ll be a laggard, allocating our limited resources for the best functionality with appropriate safety and robustness.  Also, will not deploy a technology until privacy protection is addressed with appropriate business associate agreements and security controls.

This ExploreIT powerpoint illustrates some of our projects in progress, created  by internal staff supplemented with external products and experts selected by our operational teams.

We hope to commit more than $1 million to our innovative efforts this year through a combination of in kind efforts and philanthropy.    Thus far, we seem to be achieving a perfect storm of alignment between business owners, internal developers, and technologies to leap frog existing solutions.

Thursday, March 16, 2017

Building Unity Farm Sanctuary - Third Week of March 2017

With every passing day, Unity Farm Sanctuary increases its capacity to host public educational sessions, retreats, and events.    Our first few months were focused on the historical Unity Hall building.   As you’ll see in the photographs below, we’ve made substantial progress.   The next few months will be focused on expanding our capacity to give "forever homes" to animals in our community.    A design, which works for just about every species we’ll encounter,  is done.    By May it will be a reality.

Here’s a view of the rooms of the Sanctuary, all assembled from local basements, attics, and donations.

As you enter the original 1833 door, you come upon the meeting room, which is where the weekly meditation group gathers and where we host lectures about diverse topics such as sustainable agriculture, organic farming, and animal care.

The kitchen and surrounding breakfast room is where our volunteers gather for early morning coffee (we have a commercial Bunn coffee machine for an endless pot of organic blends).    We will be hosting farm to table events using all Unity Farm products starting this Spring.

The office is where we interview volunteers, have private meetings, and arrange animal placements.   The 1760's grandfather clock is still accurate to the second.

The dining room has been restored with its original lighting fixtures, gas lamps converted to electricity.

The library is filled with animal care books and natural artifacts from the surrounding ecosystem.

The bedrooms upstairs are where people stay during our retreats and overnight events.   We’ve completed the restoration of 4 rooms thus far.  

In the Schoolhouse bedroom, you’ll find a desk from the early 1800s where a local student spilled ink while practicing penmanship on the wood - he/she wrote "Boston, Concord, Eastport (a historical reference to Cape Cod)" in perfect script.  The low post bed is a New England country style design found in rural homes during the second half of the 18th Century.

In the Brass bedroom, you’ll find an 1800’s brass bed, a 1700’s maple dresser, and rocking chair overlooking the goat paddock

In the French bedroom, you’ll find an 1800’s french bed (which I rebuilt to modern mattress sizing) and a collection of 1700’s horse lithographs

In the Pineapple bedroom, you’ll find a chest owned by an 1800’s Brown University professor and a traditional New England pineapple bed, as well as an 1800’s rocking horse.

Next week, I'll post photographs of the Williamsburg bedroom with it’s 1760’s bed and clawfoot bathtub.   We’re restoring the room color paint to an early 1800’s grey-blue.

The loft is a 1000 square foot space with a distressed wood floor looking out over the horse paddocks.   The yoga classes, silent retreats, and art events are held here.

By April, our work on the buildings will be done and we’ll focus on the new new animal rescue areas.   When we plan a paddock and run in, we pay special attention to manure management, rotation of animals so that the land has a chance to recover, and utilities (electical/water).    Here’s a map of that shows the new acre of animal areas between the farmhouse and the sanctuary.    We’ve given a great deal of thought to workflow, so that volunteers can easily move animals from paddock to paddock without difficulty. You’ll see that every care area is connected with lanes and gates, so that no volunteer can lose an animal.

Palmer the turkey is really adapting well and he’s a well established member of the community.   In a few weeks, we’ll hear about possible donkey and sheep adoption.   In the meantime, we continue to support all the creatures of Unity Farm Sanctuary in the cold, wind and snow of the waning 2017 winter.

Thursday, March 9, 2017

Building Unity Farm Sanctuary - Second Week of March 2017

When you run a sanctuary, you need to be agile.   We received a message that we had until 1pm to rescue a heritage turkey or he would be eaten.   We drove the Unity Farm van to pick him up and  within 2 hours he was living at Unity Farm Sanctuary.   Meet Palmer, a 2 year old Royal Palm turkey He’s social, friendly, and very interactive.   He gets along with all the other birds, the dogs, and pigs.  I was able to pick him up and move him into the barnyard without a struggle.    

Although we now have over 150 birds, we have little experience with turkeys.   We let Palmer choose his first roosting spot and he decided to go high - to roost on top of the chicken coop the first night and on top of the goose/duck pen the second night.   At this point, he’s very relaxed around all the other birds and spends most of his time with the guinea fowl.    You can now hear his “gobble gobble” sound throughout the property as he free ranges over 30 acres.

Although the temperatures have become cold again and snow is falling, the birds are all laying again since the days are growing longer.   Here’s what a typical trip to the coop brings - everything from pullet “fairy eggs” (small) to goose eggs (large).

Kathy and I have begun to layout the new pastures and paddocks now that we’ve cleared an additional acre for animals.    The sanctuary could potentially house almost anything, so we made a list of all the creatures we may be called on to rescue

Guinea Fowl
Emus (a placeholder for the exotic and unexpected)

so we’ve designed a set of paddocks that can flexibly accommodate all these species, while preserving biosecurity and ensuring everyone gets along.

We’ll begin fence construction the last week of March.

And what’s this about emus?   Kathy and I have used the term “elephants and emus allowed” to describe the flexible farming regulations of our town.    When I rescued the turkey, here’s who I found living with him.

We’ve heard about 2 emus that may need a new home.    Since they run 30 mph and are about as large as a human, keeping them safe and happy could be a challenge.

This weekend we’ll be continuing our work on the new paddocks, preparing for even more snow, and doing some of the last repair work on the sanctuary building - grouting the kitchen counters, repairing  broken screens, and rewiring the dining room to install the original lighting fixtures, which were recently donated to the sanctuary by a previous owner.    Over the next few weeks, I'll post a virtual tour of what the fully restored sanctuary looks like, room by room.

Thursday, March 2, 2017

Building Unity Farm Sanctuary - Fourth week of February 2017

In New England we often say that if you do not like the weather, wait 5 minutes.   The high this week at Unity Farm Sanctuary was 70F and the low was 5F.   We’ve had blankets on the horses overnight then removed them at dawn to prevent overheating.   The flowers are blooming now but have frozen solid over cold nights.  I fear that our apple crop will be diminished since the young buds will be damaged by killing frosts.   There’s not much I can do to battle an unexpected cold snap.

The cold means that every creature - wild and domestic - struggles to stay warm.   Turkeys and deer are coming to the barnyard seeking food.   Yesterday we woke up to a new “puppy” running through the barnyard.    The photos below show the young fox searching for mice and voles in one of the rock walls.

The newest pig at the Sanctuary, Penny Blossom, is a bundle of energy.   She really values time with her humans and I’ve been taking her on multi-mile walks every day.    She’s very comfortable with her leash and obeys every command.    At the end of the walks, she’ll sit in my lap for belly rubs.   She’s very comfortable with the other creatures at Unity Farm and wanders around the barn yard on her own (with supervision).

Hazel, our “alpha” pig, is a bit jealous.  I’ve made sure she gets her share of belly rubs too.

On the days when the temperature creeps above 50F, the bees have started to gather pollen from emerging skunk cabbage.   It’s been a rough winter for bees in New England because of the spread of viruses by varroa mite.    We’re expecting 50% losses.

This week we put out a call for volunteers to serve as companions to our animals - offering time to help with their socialization and care.    The response has been overwhelming.   As we add more creatures, we’ll increasingly depend on volunteers since Kathy and I are limited by the 168 hour week.   We only accept animals at the sanctuary when we are confident we can support every aspect of their lifecycle and needs.

This weekend, we’ll be continuing work on the new sanctuary paddocks and animal shelters.  Next Friday (if the weather holds) we’ll begin clearing another acre of land.  Our design for the new rescue areas will require half a mile of fencing, to be installed in the Spring.    With every passing week, the sanctuary grows, providing the infrastructure to support our evolving animal community.

Wednesday, March 1, 2017

Next Steps for the National Healthcare IT agenda

At HIMSS, I listened carefully to payers, providers, patients, developers, and researchers.   Below is a distillation of what I heard from thousands of stakeholders.

It is not partisan and does not criticize the work of any person in industry, government or academia.   It reflects the lessons learned from the past 20 years of healthcare IT implementation and policymaking.    Knowing where we are now and where we want to be,  here are 10 guiding principles.

1. Stop designing health IT by regulation
Through its certification program, ONC directs the specific features, functionality, and design of electronic health records.  As a result, technology developers devote the majority of their development resources to fulfilling government requirements instead of innovating to meet market and clinician demands.  The certification program has established a culture of compliance in an industry ready for data-driven innovations.  ONC’s role in the health IT industry made sense eight years ago when IT adoption in healthcare lagged considerably behind all other sectors, but today the certification program impedes a functioning market and must be reformed.

2. Align certification with Meaningful Use (MU) and MACRA/MIPS requirements
ONC’s certification program is increasingly disconnected from CMS’s work to streamline pay-for-performance programs. For the first several years of the MU program, certification criteria were tied to MU measures. Though burdensome, certification was directly related to clinicians’ successfully meeting MU requirements. CMS has made progress toward simplifying MU and now the ACI category of MIPS, but unfortunately ONC has not followed suit in the certification program. As a result, the certification program is filled with outdated requirements and is a significant drain on health IT developer resources with no incremental gain to patient care.  The certification program needs to be limited to verification of functionality necessary for success in Medicare and Medicaid payment programs.

3. Recognize that information flows best when there is a business case for doing so, not a government mandate
Well-intended government attempts to mandate interoperability have led to unintended consequences that stifle innovation. In every other sector like finance or travel, market dynamics serve as a sufficient driver for information fluidity; policy frequently impedes such a reality in healthcare. ONC should set the conditions for private sector led interoperation efforts—the private sector has and will continue to make tremendous progress to bring seamless information exchange to healthcare. When interoperability is essential to the success of health systems and medical practices, market forces will deliver robust solutions that increase the utility and value of information exchange.

4. Improve access to CMS claims data to drive care coordination
The government does not share its own cost and quality data associated with the millions of taxpayer dollars spent through Medicare and Medicaid. If clinicians had access to the complete claims data for their patients, it would enhance interoperability, driving improvements from increased price transparency for patients to better informed decision-making and communication by clinical teams.  There is no legal barrier to CMS sharing its claims data with HIPAA covered entities for the purposes of treatment, payment, and healthcare operations.

5.  Eliminate the Enhanced Oversight Rule
ONC’s Enhanced Oversight and Accountability final rule augments ONC’s regulatory authority over health IT products at a time when efforts should be exclusively focused on reducing the burden of the certification program.  The rule further increases the administrative burden and cost associated with certification for both health IT developers and government bodies alike.  Vendors will have to devote continued attention to proving ongoing compliance with the rule, further limiting the resources that they can devote to responding directly to consumer needs.  Program add-ons, such as this increased oversight, will not improve the certification program or the usability of health IT products.   Additionally, the authority laid out in the rule is beyond the scope that Congress envisioned when it established a certification program and it paves the way for future overreaches that will inhibit the entire industry.

6.  Avoid a heavy-handed approach to patient safety.
Patient Safety Organizations (PSOs, established under the Patient Safety and Quality Improvement Act of 2005) play an important role in improving care quality by providing a space for the healthcare community to confidentially share and learn from patient safety issues. It is essential that ONC leverages this existing framework as it thinks about how to ensure patient safety in health IT, as opposed to a framework centered around government investigation and oversight. A government-led approach has been demonstrated to lead to a “shame and blame” culture where the penalties and government intervention associated with safety issues lead stakeholders to keep issues confidential, rather than ensuring that the entire health IT community can learn from issues experienced by one provider or vendor. Safety is a priority for every health IT vendor. ONC should ensure that it is not unnecessarily inserting itself between vendors and providers when it comes to learning about and swiftly resolving issues.

7.  Establish a national patient identifier.
HIPAA called for the creation of a national patient identifier to improve efficiency and safety.   While patient-matching technology and processes have improved tremendously since HIPAA was enacted, a national patient identifier would still offer considerable efficiency and safety benefits and would remove a barrier to seamless interoperability.

8.  Improve access to CMS data on providers to spur the creation of market-based provider directories.
CMS has the most comprehensive nationwide information on providers in the country.  By making this information available as a "shared service" through industry-standard APIs or formats, innovative developers will be able to create a wide variety of value-added applications for providers and patients.  The same might also apply to record location leveraging CMS's knowledge of provider-patient relationships.  While this information is admittedly more complex due to privacy issues, there are already market-based record location services available through CommonWell and Surescripts that CMS could either supplement or learn from.

9.  ONC should focus on "coordination" of government entities.
Federal government provider organizations (DoD, VA, INS, etc) are an important part of the health care delivery in virtually every market of the country.  Yet, in most markets these organizations do not participate in the interoperability landscape.  These organizations can drive standards-based interoperability not through regulations but through market action.  Deploying industry-standard interfaces and APIs and actively participating in "retail" commercial exchange such as CommonWell and Carequality will do more to advance interoperability than any amount of ONC "enhanced oversight".

10.  Drive alignment of uniform patient privacy laws across the country.
It's obviously not practical to try to battle each of the 56 states and territories one-by-one, or to try to statutorily enact Federal pre-emption of state privacy laws.  However, there are many examples in other industries where the Federal government has motivated alignment of state laws without formally trying to preempt those laws (speed limits, for example).  Active participation by Federal agencies in nationwide health information exchanges (#9) that adhere to nationwide HIPAA provisions would be one way to drive this.  Tying use of Medicaid funds for local HIE initiatives to alignment with nationwide practices might be another.

Thursday, February 23, 2017

Building Unity Farm Sanctuary - Third Week of February 2017

As the weather begins to warm, work on the sanctuary gets easier.    Snow and ice are melting.   We’ve taken the blankets off the horses and left the doors/windows on barns open overnight.   Turkeys and deer are looking for food on the newly visible ground, causing the dogs to bark all day and night.

This week, Millie, a 23 year old Welsh pony arrived at the sanctuary.   She immediately bonded with Pippin, our 30 year old Welsh pony.   Amber and Sweetie hang out on one side of the large paddock, Millie and Pippin on the other.   Everyone is getting along well.

Millie’s arrival was a bit rocky.   Her owner drove Millie from Central Massachusetts to Unity Sanctuary and one mile from us, the diesel truck pulling the horse trailer just stopped.   Nearby police arrived to direct traffic and Millie was safely removed from the trailer and walked down a side street.    One of our neighbors, the Dowse family, saw the problem and immediately came to the rescue, hauling the trailer out of harm’s way and to the sanctuary.  The truck was towed back to Central Massachusetts and a mechanic found  fuel line failure.

Now that the floors and walls of the sanctuary have been refinished, we’re in full swing with classes and meetings.  Here’s a glimpse of our efforts to restore colonial colors to every room.

Friday yoga meets in the third floor loft of Unity Hall.  Sunday drop in meditation meets in the great room on the first floor of Unity Hall.   Retreats are scheduled for March.   The commercial-grade heating, plumbing and electrical systems are ready for them.

My nights and weekends (when not at HIMSS) have been spent on carpentry, window repair, and furniture refinishing.  At this point we’re completed our search for 1800’s furniture in local basements, attics and even the town dump.   Here’s what it all looks like.

This weekend, Penny the Yorkshire pig arrives we’ll begin the process of socializing her into the herd.   She’ll need extra reassurance since this will be the first time she’s left her mom/dad and the comforts of her home.   We’ll keep her safe for a year, hoping that she’ll return to her “parents” once they’ve found a new place which a dedicated pig habitat.   We'll work on trails, paddock planning, and recovery from the past 4 months of below freezing weather.

Wednesday, February 22, 2017

Dispatch from HIMSS 2017

As I wrote last week, I expected 2017 HIMSS to be filled with Wearables, Big Data, Social Networking concepts from other industries, Telemedicine, and Artificial Intelligence.

I was not disappointed.   42,000 of my closest friends each walked an average of 5 miles per day through the Orlando Convention Center.  One journalist told me “It’s overwhelming.  You do your best to look professional and wear comfy shoes!”

After 50 meetings, and 12 meals in 3 days, here’s my impression of the experience

1.  Wearables, while still relevant have gone from the peak of the hype curve to the trough of disillusionment.   Google Glass, smartwatches, and innovative fitness trackers have not quite achieved their promised potential in healthcare and no one is quite sure how to integrate their data into the workflow.    That being said, Internet of Things is bigger than in previous years, with home scales, glucometers, and blood pressure cuffs becoming more connected than ever before.  Middleware like Apple Healthkit has significantly reduced the interfacing burden.

2.  Big Data has morphed into Care Management and Population Health.   We’re at a point in history when healthcare data has become digital but few are sure how to turn that data into wisdom.   Decision support services that analyze problem lists, medications and genomic data, producing customized care plans are emerging.  The challenge is connecting them to the EHR workflow.   The Argonaut work group met for a few hours to decide on the next interoperability capabilities for FHIR and chose scheduling workflow and clinical decision support integration.  This means that any third party developer will be able to integrate their analytic functionality into EHR workflow, generating alerts and reminders and scheduling services (appointments, surgery, infusions/therapy, referrals, and even post acute care) with limited effort and cost.      To me the most important theme at HIMSS 2017 was that FHIR/APIs, cloud hosted services, and EHRs will come together in 2018 similar to the way the iPhone spawned the app store.   Assume every EHR company will have a curated app store and sandbox for developer education/pilot testing within a year.

3.  Value-based purchasing has generated an interest in customer relationship management - the patient as partner and consumer.  As reimbursement moves from fee for service to quality/outcomes driven risk contracts, incentives are aligned to provide wellness services, “care traffic control”, and loop closure.    EHRs are not optimized for these functions, so third parties are offering cloud-hosted customer relationship management for healthcare.

4.  Telemedicine and Telehealth continues to grow as efforts to reduce total medical expense move care from downtown academic tertiary referral facilities to lower cost, more convenient alternatives in the home.  Telemedicine means many things and ranges from on demand virtual urgent care visits to store/forward second opinions to expert staff augmentation from a distance.   Products are evolving that enable telemedicine record keeping, billing, and mobile device secure communications.

5.  Artificial Intelligence/Machine learning is the new “plastics”   .   There is no question that AI is the peak of the hype curve this year.  We need to be measured about our expectations for this technology.   Computers do not “think”,  they use pattern matching to focus the attention of humans, separating signal from noise.    There are great use cases for machine learning - automating sorting of paper medical records for scanning by predicting metadata, scrubbing personal identifiers from unstructured data, and suggesting reasonable ICD10 codes for episodes of care.    It’s not likely that an AI system is going to read the Merck Manual tonight and replace your doctor tomorrow.

Although my voice is nearly gone, I’m leaving HIMSS with optimism for the industry.   EHR vendors will increasingly share data with each other and with third party developers.  Usability will improve as new applications and analytics reduce clinician burden.   Patients will increasingly be equal members of the care team providing objective and subjective data from devices and mobile apps in their home.  

As I’ve said before, I believe the next phase of history belongs to the private sector, so for all of the developers, customers, and experts at HIMSS, it’s all up to you.

Wednesday, February 15, 2017

Preparing for HIMSS 2017

Next week, 50000 of our closest friends will gather together in Orlando to learn about the latest trends in the healthcare IT industry.

What can we expect?

I’ll be giving a few keynote addresses, trying to predict what the Trump administration will bring, identify those technologies that will move from hype to reality, and highlighting which products are only “compiled” in Powerpoint - a powerful development language that is really easy to modify!

Here are a few themes

1.  The Trump administration is likely to reduce regulatory burden but is unlikely to radically change the course of value-based purchasing.    This means that interoperability, analytics, and workflow products that help improve outcomes while reducing costs will still be important.   Fee for service medicine will diminish over time, so focusing on quality healthcare will be more important than increasing the quantity of tests, procedures, and visits.   Novel products and services will be needed since the existing EHR is not designed for optimizing wellness, it’s designed for documenting/billing encounters.

2.  Precision Medicine that tailors care plans and therapeutics based on the unique characteristics of each individual will continue to be important.    Although there is much discussion of genomic medicine but even simple innovations can make an impact.  For example, my wife needs to take 3.75mg of Methimazole every day but the medication is packaged as a 5mg tablet she needs to cut into quarters.  Why not offer a 3D printer that simply “prints” the tablets you need each day?

3.  Care Management solutions that treat the patient as customer will continue to be important.   Sharing care plans, monitoring progress on those plans, and engaging patients/families as a shared decision maker will require innovation.

4.  Artificial intelligence/machine learning will be at the peak of the hype curve this year.   IBM Watson will not replace clinicians, but the notion of using software for pattern matching does work well.

5.  Internet of things, patient generated healthcare data, and telemedicine/telehealth will be increasingly important tools as we strive to reduce total medical expense, address the needs of an aging society, and enable our clinicians to practice at the top of their license.  

I’ll be running from venue to venue Sunday-Wednesday.   See you there.

Thursday, February 9, 2017

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.

Wednesday, February 8, 2017

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.

Thursday, February 2, 2017

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.

Wednesday, February 1, 2017

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.

Thursday, January 26, 2017

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.

Wednesday, January 25, 2017

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.

Thursday, January 19, 2017

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

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.