Building Unity Farm - Creating a Brand

As we move from the farm building stage to the farm operations stage, Kathy and I are turning our attention to the basics of running our farming business.   We've filed articles of incorporation (Unity Farm LLC), created a formal land management plan for review by the town of Sherborn, built basic processes for recording income/expenses, documented options for selling our products and formulated a multi-year strategic plan leading to full recognition as an agricultural enterprise.

Creating a brand is an important step for us as we begin to build awareness of our apples, honey, mushrooms, alpaca fiber, handmade soap, and blueberries.  This morning I heard the 1970's New Seekers song "I'd Like to Teach the World to Sing" and it comes very close to the Unity Farm vision (replace Turtle Doves with Guinea Fowl)

"I’d like to build the world a home
And furnish it with love
Grow apple trees and honey bees
And snow white turtle doves"

Since that song is so closely associated with soft drink sales, we'll need another approach.

At the entrance to Unity Farm, a large specimen-quality sugar maple greets visitors to the property.   We've used its silhouette, shown above, to create  a logo and label for the farm.

For individual products, we'll use silhouettes of  apples, bees, Shitake mushrooms, alpaca, etc providing us name recognition and a standard labeling platform for everything we sell.

We have a Facebook page and we'll create appropriate twitter, pinterest, and other social media sites.

We've already collected this season's alpaca fiber and are spinning it into wool.   We're harvesting our first honey over the next few weeks.   We'll have our first berries in August and apples in October.   Our quantities of everything this first year will be very limited.   Likely our first real sales and the possibility of a "mushroom CSA", selling guaranteed shares of Shitake mushrooms, will be in 2014.

In the meantime, we're continuing farm development.  We'll finish the hoop house (a kind of plastic sheeted green house) in July and have another mile of forest trails completed by the end of Summer.    We're also picking peas and strawberries from a nearby farm, making our own jam as we await the maturity of our own berries and other produce.

I'm off to Kyoto this weekend, so my next post will be dispatch from Japan, where I'm keynoting the IEEE conference this year.

Affiliation Planning

Many healthcare organizations  are discovering that accountable care reimbursed via global captitated risk contracts requires more primary care physicians and a more tightly coupled delivery network including suburban hospitals, home care, and long term care.   Affiliations, mergers, and acquisitions are accelerating to meet these needs.

From an IT perspective how are to respond to this organizational change with agility and efficacy?

We could rip and replace everything everywhere and mandate a single vendor solution for every workflow at every new location.

That would create standardization, but it would also consume more capital than we have at time when Meaningful Use Stage 2, ICD10, and compliance requirements have already committed all available IT resources.

A balanced approach is to enumerate the workflows we need to support and then build upon existing applications and infrastructure to automate priority processes that improve quality, safety, and efficiency.

In the past, we've used web-based viewers,  health information exchange, registries/repositories, master patient indexes, and secure email to link together organizations and coordinate care.

Can we share every data element for every purpose in every circumstance?   No.   Can we rapidly achieve "good enough" at low cost.   Yes.

Our solutions to date have been project based - implementing those point solutions that best fulfill a specific affiliation.   The pace of change is so intense that we need a more scalable solution - templates for new affiliations, mergers, and acquisitions.

What services do we offer?  What services do our new partners want?  What do we centralize?  What do we federate?  What do we change and importantly what do we not change?

Over the next few months, we'll do the following

1.  Ask IT infrastructure and application managers to list the services they have been tasked to provide in the past when new affiliations have been formed

2.  Ask existing affiliates and new affiliates about their experience during the partnership process.    Inventory their existing applications and their plans for upgrading/changing them.

3.  With a sense of supply (the services we offer) and demand (the services desired), we can create templates for affiliations, mergers, and acquisitions - a kind of Chinese menu that will enable us to rapidly develop FTE, capital and operating budget requests when new partnerships are planned.

Sometimes I'm asked to budget for projects that are not yet formalized, often with ill defined scope.    If I could present a set of templates to the Board and Senior management noting that partnerships fall into three categories - small, medium and large, each with an estimated price tag, I could craft a yearly operating plan and capital budget that includes x smalls, y mediums, and z larges, ensuring promises made are backed by the people, funding, and attention necessary to support timely delivery.

I will post my templates once they are developed.

If any of my readers have developed such templates, I welcome the opportunity to review them.

Connecting the Meditech Hospitals in Massachusetts

Yesterday I joined several Massachusetts CIOs at a Meditech healthcare information exchange kickoff meeting.  

Here are the slides we used.

Meditech has chosen to do the right thing - support the Direct protocol without requiring a vendor specific HISP, an interoperability "subscription" or transaction fees.    Nationwide, any of Meditech's Meaningful Use Stage 2 certified platforms - Magic 5.66, Client/Server 5.66, or  6.07  can support the Direct implementation guide (SMTP/SMIME) and the SOAP/XDR addendum.

The Massachusetts HIE, the Mass HIWay, has been live since October 2012 and now transports thousands of transactions per day among providers, payers, patients, and government.  Our goal in 2013 is to add more organizations and more use cases.    Meditech provides about 70% of the hospital information systems in the Commonwealth, so it is critically important that Meditech integrates well into the state's cloud-based HISP.

Over the next few months, a diverse array of hospitals will work closely with Meditech and state government to implement production HIE transactions.

Earlier adopters will include Jordan Hospital, Holyoke Hospital, Winchester Hospital, Berkshire Health Systems, Harrington Hospital, and Exeter Health (New Hampshire)

Use cases include transition of care summary exchange, public health reporting. lab results reporting, admission notification, and ED arrival notification.

Once these pilots are complete, we'll spread Meditech connectivity through the Commonwealth.

With other EHR vendors, which are requiring vendor specific HISPs, we're still working through the trust issues (authentication is easy, authorization is harder) that enable HISP to HISP communications among those clinicians who have agreed to all our privacy policies.    Once this work is done the number of clinicians with HIE connectivity will accelerate as network effects incentivize data exchange for care coordination, care management, and population health.

Poem - Do Not Resuscitate

Do Not Resuscitate



I can say

your father is dying.

I can say

wishing will not make it so,

belief doesn't change a thing.



I can say

love does not conquer all,

miracles are pretty stories told in church,

the movies you saw as a child are lies,

blind hope is not a recipe for success,

underdogs usually lose,

death is not the worst thing, it is just

the last thing.

But for you

Building Unity Farm - Emergency Preparedness

In the month of June, we've had 10 inches of rain at Unity Farm (to view our weather station data click here).

Although our paddocks, pastures, and trails are normally dry, we've accumulated water in ways that impacts our ability to care for the animals.  The picture above shows one of our paddocks after a deluge of rain.   A manure pile that is under water is a bad thing.

What did we do?   I purchased a 1/2 horsepower submersible sump pump  and attached 1 1/4 inch sump pump hose to maximize outgoing water flow - a garden hose would have been too limiting.     Sump pump hose is sold in 25 foot segments because sump pumps are designed to go from basements to outdoors over a short distance.   In our case, we needed to pump 40,000 gallons of water into  a dense forest that would easily absorb the flow and return it to our water table.   I used 1 1/4 barbed couplings and hose clamps to link together 150 feet of sump pump hose.  

I built a cage of 23 gauge hardware cloth and submerged the pump inside the cage to ensure floating debris did not clog the pump.

The end result was a water flow of about 4000 gallons an hour from paddock to forest.   After 12 hours of pumping, the paddock was transformed from a lake to puddle.  

After mastering this technique, we're now ready for any flood related emergency.

Too much water is one challenge, but what about too little?   We have a well that consistently produces 8 gallons per minute of clear, chemically perfect water.  However, the well depends upon electricity.    If we lose power due to a storm, we have 50 gallons stored in the basement which will serve the needs of the household.   But, what about the animals?

To ensure we can keep all the animals of Unity Farm hydrated, warm, and safe, the farm has a 20 kilowatt generator and four propane tanks.   The entire barn, heating system, food storage, water supply, and internet connection can run off grid for a few weeks.   The pump system I described above is powered from the chicken coop, which is also backed up by the generator.

Last year, we replaced all the well equipment which had reached end of life.   In addition to water flows to the barns and paddocks, we do have drip irrigation keeping all our fruit trees and produce plantings moist.    Just as we're ready for floods, we're also ready for droughts.

Finally, we have a fully stocked root cellar with about a year of food kept at 60 degrees, so if there is a very significant man-made or natural disaster, we should be self sufficient.

Every day at Unity Farm is a learning experience.  Thus far, our emergencies have been few, but we're prepared for whatever may come.

The June HIT Standards Committee

The June HIT Standards Committee focused on novel transport standards for patient mediated exchange, an overview of patient/family engagement tools, updates on formulary downloads, use cases for image sharing, and lab ordering standards.

Dixie Baker and David McCallie presented the NWHIN Power Team review of the emerging transport standards for consumer exchanges that I believe will accelerate all types of interoperability in the next few years - the HL7 Fast Healthcare Interoperability Resources (FHIR, pronounced "Fire") initiative , the RESTful Health Exchange (RHEx) Project and the Blue Button Plus (BB+) Initiative.   It's clear to me that the combination of REST for transport, OpenID/OAuth2 for authentication/authorization, and FHIR for content will be a winner as we scale interoperability to the national level.

Next, Leslie Kelly Hall presented the efforts of the Consumer Technology Workgroup to prioritize patient and family engagement standards including structured data capture from forms/questionnaires and care plans.

Jamie Ferguson, with John Klimek from NCPDP, presented the preliminary recommendations of the Clinical Operations Workgroup for adoption of formulary standards.    We also discussed use cases for image exchange (provider to patient, provider to provider, provider to care team) and endorsed the S&I framework efforts on lab ordering standards.

Finally, Doug Fridsma and Set Pazinski provided an ONC update.

A very good meeting with exciting new standards evolving to support Meaningful Use Stage 3 and beyond

Making a Difference

Although I usually reserve Thursday for personal blogs, Father's Day was a time for reflection that enabled me to put aside the endless emails, operational tribulations, and budget season stresses to think about what really matters.

In my 51 years, 2013 marked the first time I've had no father with me on Father's Day.  For the first time, I've taken on the mantle of "alpha" father for the family.

I celebrated Father's day with my wife, daughter and her partner David, enjoying a Japanese lunch and helping them rewire the kitchen in their new apartment.   They rent one of 4 units in a 1910-era shingled house in Medford.   We braved the dungeon-like basement to find the old breaker box and located the power controls for the kitchen.    I taught them how a GFCI receptacle is wired, carefully isolating the Load and Line sides, the hot wire, the common wire, and the ground.    We then built new kitchen shelving for her pots and pans.    It was a perfect Father's Day, serving those around me and making my daughter's life easier.

I called my mother, as I have done every day since my father's death, to check on her progress.  She's gardening, taking daily walks, and keeping her brain busy with numerous cultural and social activities.

So, what part of this inspired me to think about what really matters?

Will my tombstone read

"He balanced his budget 20 years in a row"
"He addressed all regulatory requirements for over 2 decades"
"He completed all his annual operating plan goals and more"

Unlikely.

If in some small way, I empower my daughter to fledge from the nest, taking responsibility for running a household and finding her own way in the world, I will have created a legacy that could last for a century.

If in some small way, I enable my mother to maintain her wellness, learn new technologies, and experience a rich "act two" after my father's death, I will have made a real impact on her life.

Both are examples of making a difference.

As I look at my weekly calendar, about half my waking hours are spent on operations, a quarter on planning the future, and quarter in service to my family and community.

It's the last quarter, when I give my time, that has the greatest chance of impacting the long term future of those around me, accelerating the progress of the next generation, and catalyzing good outcomes in the world.

While balancing a budget is a must do, it's quickly forgotten.   You're only as good as your last budget cycle or your last successful project.

However, if your family, your colleagues, and your students feel inspired by something you've said, a situation you've created, or a barrier you've broken down, then you've created a memory that can last a lifetime.

So next time your equanimity is challenged by a person, situation, or event in your job, remember that such issues are transient.    Focus your emotional energy on that which really matters and you'll make a difference.   That's the pot of gold at the end of my rainbow (photo taken at Unity Farm a few hours ago)

Building Unity Farm - Little Glamour, Lots of Laundry

My wife and I owned and operated a small winery on the Marin/Sonoma border in Northern California when we were in our 20's - from 1986-1991.   When I told my colleagues at the time that I ran a winery, they commented on the romance, art, and elegant lifestyle it implied.   It was agriculture.  It was hot, sweaty, and dusty.   You could make a small fortune in the wine business - as long as you started with a large fortune.   I relished the experience, but it was not elegant.

In many ways, running a small farm is the same.   The notion of a hobby farm or gentleman's farm sounds so Thoreau.    In reality, it's a lot of laundry.

Every morning before leaving the farm at 6:45am for the commute to Boston, I feed the animals, fill their water buckets, and clean stalls.   I make sure that no predators visited overnight, that crops were watered by irrigation systems, and that compost is moist but not too moist.

The picture above illustrates what it's like to manage the manure of 50 animals - that's a 16x16x3 foot compost pile.

Farm work is extremely satisfying and is an essential part of maintaining my equanimity.  Shoveling manure, hauling hay, and splitting wood are very Zen.

The difference between farm life  and suburban residential life is the scale.

Have you ever mulched your garden?    The picture below is the mulch pile for the trails of Unity Farm.  I run the dogs on the trails every night and they enjoy climbing the wood chip pile before it becomes trail mulch.

Weekends are filled with joyful work - every moment from 6am to 6pm is constant movement.

By the end of the day, I'm covered with hay, dirt, manure, forest debris, and animal hair.

The clothing I wear on the farm is the same tough climbing gear from Arcteryx that I've worn for years as an alpinist.   Not only does it stand up to the rigors of farm work, it also lasts through the repeated washings (at least two per weekend) needed to return the fabric to its baseline state.

The scale of Unity Farm as described in our LLC filing and Chapter 61A application (agricultural status) is

"Unity Farm raises alpaca for fiber for production to spun yarns.
        This can include milling of blankets or other objects beyond yarn.
         Also possible is the sale of cria (baby alpaca), as a result of our breeding plan

Fruits, eggs, honey, and gourmet mushrooms are planned components of the farmstand.
          Possible addition of other seasonal crops from the hoophouse
          Local flowers possible
       
Considerations include pasturage, cropland, location of farmstand, and web sales. Ecotourism and Northeast Organic Farming Associaton certification are to be considered."

We're not an agribusiness, we're a local community resource.    We may be the size of a gentleman's farm  but we're not very gentlemanly.   Little glamour, lots of laundry.   If you want to try it yourself, here's some of the best advice I've ever found.

The Healthcare Information Technology Maturity Model

Previously I wrote about Frameworks for IT Management, including the Capability Maturity Model.

Recently, I collaborated with Intel Corporation, HIMSS Analytics and Innovation Value Institute to evaluate the BIDMC IS organization and better understand our strengths and weaknesses.  

Here's an overview of the process

The report evaluated our ability to manage IT like business, manage the budget, manage our capabilities, and manage our portfolio of projects to optimize business value.

Given the volatility and uncertainty in healthcare and technology, it's important to continuously evaluate priorities, opportunities, and threats.    Some days can feel like ADHD.    Some weeks can feel overwhelming.

As a manager, I need to focus more on the areas that need improvement and less on the areas that are good enough.

Benchmarking exercises to discover where you have high and low maturity compared with other organizations are useful.   Sometimes you do not know what you do not know.

In my career, I've moved very fast on issues such as web-enabling applications, hosting in the cloud, and securely sharing data.   I've moved slower on areas of disaster recovery, social media policy, and some aspects of formal documentation.

The HIT Maturity Model was a useful exercise that helped me focus my plans for the next year.

The great thing about being an IT leader is that our work will never be done.   Frameworks for IT management and benchmarking tools help us with the journey.

Morning After Pill Now Available Without Prescription

The U.S. Justice Department has dropped its appeal to block a ruling by a New York Federal Judge to allow easy access, over-the -counter purchase of the "Morning After" pill for birth control. The emergency contraceptive, named for women who either got caught without a contraceptive, or the condom broke, is called  Plan B One-Step.  (I guess that is when plan A fails.)  Plan B is a one dose

A Social Security Interoperability Update

A few years ago, I wrote about the groundbreaking Social Security Administration automated disability adjudication system, Megahit.

Patient sign a consent in their local social security office and that consent is digitally sent to BIDMC.   The appropriate medical information needed to support disability claims is automatically assembled and cryptographically transmitted to SSA.

Here are a few stats on the SSA/BIDMC partnership.  Since our 2008 go live, SSA has received 6,916 medical records from BIDMC (and 71,500 from hospitals and providers across the country) .  Of those, 663 BIDMC medical records  (and 7,624 from hospitals and providers across the country) triggered one or more of SSA’s business rules, which resulted in targeted decision support for SSA adjudicators, speeding the disability determinations process. Thus far in FY 2013, about 6 percent of disability cases in Massachusetts were decided within 48 hours. SSA has seen significant improvements in the disability determination process using health information exchange to obtain medical records.  In FY 2012, they lowered disability case processing time by approximately 23 percent for those cases containing medical records obtained through health information exchange.
 
When SSA receives electronic health records from a partner organization, such as BIDMC, there are many benefits:
faster disability determinations are possible for claimants,
quicker access to monthly cash benefits are possible, and
earlier access to medical insurance coverage is obtained.

Healthcare providers benefit from increased patient satisfaction rates,
reduced uncompensated care, reduced administrative costs associated with medical record requests, and
automated fiscal payments from SSA.

Here is the link to SSA’s health IT website, which provides additional information on the initiative.   It's been a very successful health information exchange project.

Answer to Image Challenge

The answer to the image challenge this week is #1 - Atherosclerosis.  Most of you got the right answer because you obviously know that the diagonal crease seen in the earlobe is known as "Frank's sign".  The sign was originally described as a marker for coronary artery disease, with a moderate sensitivity ( approximately 48%) and specificity ( approximately 88%).  Frank's sign has been

Komen Suffers For Its Blunder

How do you wreck a beloved brand?  Just look at Susan G. Komen Foundation For the Cure (Breast Cancer) and remember what a well-known brand they had.  From pink ribbons to breast cancer walks and gala events, corporate and individual sponsors were happy to give to such a worthy cause.  The "Race for the Cure" was catchy and easy to promote.

 Fast forward to January 2012 when Komen foolishly

Building Unity Farm - A Day in June

And what is so rare as a day in June?
   Then, if ever, come perfect days;
Then Heaven tries the earth if it be in tune,
   And over it softly her warm ear lays
JAMES RUSSELL LOWELL

Unity Farm is at the peak of growth now, fueled by warm days, cool nights, and Spring rains.

The Bluebird Meadow, pictured above, is filled with tall grasses and wildflowers.   The three bluebird nest boxes I built are filled with growing chicks.

The Orchard, planted just a few weeks ago, is blooming and filled with its first growth of orchard grass, timothy hay, and meadow mix.

Our 8 bee hives are filling with honey, a mixture of pollen/nectar gathered from the orchard, viburnum, and wildflowers.

Adult rabbits are running thoughout the forest and their babies are hiding in our Cotoneaster brambles

We have an active fox den on the property, midway up the drumlin in the deepest part of our forest, in well drained soil, about 100 feet from our upper wetland.   My guess is that it was an old groundhog den, since the first three feet of the main entrance were recently enlarged and dug into a tall oval shape that enables the fox to bolt out at a full gallop.    Every night when I run our Great Pyrenees through the forest they want to leave the Woodland Path  (Unity Farm has 4 paths - Woodland, Orchard, Marsh, and the Old Cart path) to explore the den.   The alluring scent of fox urine is irresistible .   The one downside to having an active fox den on the property is that one of our Guinea fowl disappeared on Tuesday night.   I believe she was laying an egg in the forest (Guineas are terrible parents) and she was grabbed by a fox before she could fly away.   I found a broken egg, a path of feathers, and no Guinea.    All the Guineas come home to roost at dusk, but on Tuesday night, only 17 of our 18 Guineas returned.

The Unity woodland is covered with ferns of all kinds - cinnamon, hay scented, and sensitive ferns.   I used my scythe to recut the trails through the sea of green underbrush.   I've also had the seasonal joy of removing poison ivy from the trails by pulling it out at the roots.

The new alpaca had their first vet visit this week and we've updated their rabies and CDT (clostridium perfringens types C and D and tetanus) vaccinations.   We checked their ears, eyes, and teeth.   All were perfect.    Since they lived with goats, we checked them for parasitic infections by gathering fecal samples.   Sometimes people wonder how I've learned farming skills.   How do you master alpaca rectal exams?  Just do it!

The most amusing part of the vet visit was checking each new alpaca for the RFID chip implants that are used to positively identify them if a fence is breached and they wander off.    The vet scanned Tahoe, our young male gelding alpaca and could not find his chip.   Just to check the equipment, the vet successfully scanned me, since she had read about my experience as one of the first humans to have implanted RFID identity and medical records technology.

The weekend ahead will be filled with mushroom log inoculation,  adding woodchips to trails, and clearing some of the fallen poplar on the Orchard trail.    There's nothing like a Spring weekend of farm chores to refresh the body, mind and soul.

Medical Challenge

This weeks Challenge from the New England Journal of Medicine is a good one.  Check out the photo (click on it to see closer) and make your best guess as to the diagnosis.  The answer will be posted tomorrow so put your answer in the comment section and check back to see if you are a good diagnostician!

What condition would cause this ear abnormality?

1.  Atherosclerosis
2.  Fabry's disease

Presenting the Security Plan to the Board

Today I presented our multi-year information security plan to the BIDMC Board Committee on Compliance, Audit and Risk.  

Here is the presentation I used.

Following our February external review of security policies and technologies, we developed a planning process, and a complete multi-year plan with timelines, budgets, and staffing requirements.

The plan contains 14 work streams, each of which has several components.   Here's a sample work stream planning document illustrating the goals, metrics, timing, and costs.

They key point I emphasized to the Board is that this security work is not just to satisfy federal and state regulatory requirements.   There are many tangible benefits of the work ahead including adoption of the NIST 800 framework, which formalizes our approach to risk management and priority setting.    We'll tightly manage user roles (access by job role rather than person),  devices allowed on the network, and remote access methods/rights.

All of this improvement does have a capital implementation cost and an operating maintenance cost, since we will be adding several new applications that require 24x7 support.

Although I did provide a detailed, phased project plan for each of the work streams, there is one planning task to do.  

Each of the components in the 14 work streams has an associated priority, risk, and cost.   Management at BIDMC will select a collection of projects to begin immediately which we believe will offer the greatest benefit, can be widely adopted by the organization and are affordable.   We will refine our FTE, capital budget, and operating budget requests once we constrain the scope of work to that collection of projects.

We'll ask the original external security reviewers, our multi-stakeholder working group, and the management committee on audit, risk and compliance to offer feedback on the go forward scope.

In many ways, BIDMC tries to be a leader in application and infrastructure innovation.   In the world of security, since risks evolve so rapidly and the future is hard to predict, we have to set scope carefully so that we're good enough - neither over or under implementing appropriate controls,  acquiring the right amount of technology, and hiring the right spectrum of staff.

Massachusetts HIE Update

Yesterday, the HIT Council met to review Massachusetts Healthcare IT progress.

Here is the presentation we used.

The meeting began with a presentation from Holyoke Medical Center, describing an ideal subnetwork - a local HIE that meets the needs of local stakeholders while also connecting to the state HIE, enabling any authorized stakeholder in the Commonwealth to send and receive summaries to/from the Holyoke medical community.

Next, I gave an update on BIDMC's progress.   BIDMC is now live sending immunization transactions to the Department of Public Health over the state HIE.  We're also sending 4000 transactions per day to the quality data center at the Massachusetts eHealth Collaborative.  Today we go live with Network Health for transition of care exchange and in the upcoming weeks we'll go live with Partners healthcare for encounter summary exchange.

Next, we reviewed HISP to HISP trust fabric approaches and consent issues.   For HISP to HISP exchange we agreed that we need both authentication (who you are) and authorization (what you can do).   Although certificate trust bundles like those offered from DirectTrust.org can address federated authentication issues, we'll likely implement authorization within the state HIE as we move from "push" models to "pull" which enable authorized users to retrieve records on demand.  

Massachusetts is an opt-in consent state and we reviewed recommendations for consent processes and language.   Our current recommendation is for HIE participants to obtain opt in consent during the general consent for care signing process and to specifically enumerate the state HIE as a means to share data in the notice of privacy practices.

We reviewed the FY14 plans for the Massachusetts eHealth Institute, the organizations in Massachusetts that accelerates EHR adoption and assists with connecting the "last mile" of provider practices to the HIE.

Finally we reviewed our plans for creating a statewide master patient index, record locator service, and the supporting web services to enable query/response ("pull") health information exchange.  We're on track for an early 2014 go live and all funding is in place.

A great meeting.