New Hep C Screening for Baby Boomers

If baby boomers weren't special enough,  now the U.S. Preventive Services Task Force has singled them out as a special group to be screened for Hepatitis C virus (HCV).  Individuals born between 1945 and 1965 are recommended to undergo this one-time blood test screening because they are at high risk for the virus.

What is it about this age group that gets special notice?  According to the

Building Unity Farm - The Trails

Unity Farm has a rich diversity of natural woodlands, wetlands, meadows, paddocks, and orchards.  The house and barn are located on an upland plateau surrounded by white pine, sweet birch, poplar, white ash, red oak, and red maple.   The woodlands to the south, west and north wrap the upper plateau.  The woodland zone includes a forested wetland that collects the upland water and directs it to the north via a swale.   To the east, the land is a grassy 6:1 slope from the top of the orchard to the edge of the forested wetland that connects to the meadow.

Over a mile of trails connects the natural features.    I've hand cut the trails with a Japanese sickle, Scandinavian Forest Axe,  and  Japanese folding saw.

Last weekend I added trail signs, made by the same company that creates National Forest Service markers.  Here's a virtual walk on the trails of Unity Farm:

Woodland trail
 This 1000 foot trail climbs through a fern grove and over a drumlin to a grove of old cedar that once lined a revolutionary war era pasture.  Old rock walls provide shelter for a variety of forest animals including foxes, fisher cats, opossum, skunks, and raccoons.     I've marked the trail every 100 feet with bird houses built from old cedar boards.   This year several busy Carolina Wrens raised their young in those houses.    A 12 foot bridge traverses the seasonal wetland in the lower portion of the trail.  I add two resting places along the walk - a painted bench at the base of an old pine and an Adirondack chair at the top of the drumlin.   An old Japanese stone lantern marks the end of the trail.   The Woodland trail connects to the Old Cart Path.

Old Cart Path
 Sherborn was founded in 1652 and town maps show an old cart path traversing Unity Farm, connecting surrounding orchards.   The Old Cart Path trail is 600 feet long and winds past our mushroom growing area, through a grove of sensitive fern, on its way down to our stream.   Another 12 foot bridge crosses the stream.   Along the way, a 30 year old teak bench sits in a sea of greenery next to a large pine tree.   This is one of the quietest and most contemplative places on the property.   The Old Cart Path connects to the Marsh trail.

Marsh trail
 We mapped our wetlands this year as part of preparing a general management plan for the property.   The Marsh trail is 800 feet long, starting and ending at our stream.   There are three 12 foot bridges along the path, carefully constructed to avoid shading native plants and to be completely non-intrusive to the natural landscape.   The trail passes an enormous old pine, a hand dug revolutionary war era well, and the site of an old windmill that pumped well water to supply the dairy farm that occupied our property in the 19th century.  The Marsh trail connects to the Meadow trail

Meadow trail
 A wildflower meadow borders the wetland and is home to woodchucks, ducks, wild turkeys, deer, and 4 of our beehives.    A 600 foot trail crosses the meadow and connects to the Orchard trail.

Orchard trail
 We created the orchard in 2013 and this 800 foot trail meanders between the orchard fence and the rock walls bordering the wetland.   The trail is lined with old cedar, maple, and oak.   Our Great Pyrenees enjoy running on this trail in search of rabbits, guinea fowl eggs, and deer.   A 6 point buck, a doe, and fawn graze along this trail, making for some interesting walks when 200 pounds of Pyrenees discover the deer (the dogs outweigh me by 35 pounds)

Although these trails have given us access to every portion of the property, there is still mystery to be found.  The forests, wetland, and fern groves are so dense that I'm constantly finding new artifacts,  animals, and plants.   Last week I found 3 intact Horlick's Malted Milk bottles from the 1920's on the Woodland trail, a fox den on the Orchard trail, and wild Concord grapes on the Marsh trail.   Building, maintaining, and walking the trails of Unity Farm could keep me busy for a lifetime.

Building Unity Farm - Followup on Our Breeding Program

As I mentioned in last week's post, the next step after breeding alpacas (and llamas) is a pregnancy evaluation known as the spit test.

A male and a female are placed together and if the female, kicks, spits, and generally shows disdain for the male, she is pregnant.    

On Saturday, we placed Midas (our gold colored male) with Ella (mother of 2 alpacas) together in our pasture.  Immediately, Ella spit, kicked and placed her body against a fence line so that Midas could not approach her.   We quickly returned her to the barn.   It appears that she is pregnant but we'll know definitively in 11 months.

We placed Midas and Persia (a maiden) together in the pasture.   Persia nuzzled Midas and then placed herself in a breeding position.  She's likely not pregnant.  We left them alone for several hours and we'll try another spit test this weekend.

We found another Guinea nest in forest and now have 63 fertile eggs to tend.  We have two incubators  - one from Farm Innovations and another from GQF giving us a total capacity of 83 eggs.   We have a brooder from GQF and use heat lamps and large Rubbermaid bins for older chicks.

Guineas are wonderful birds and have kept our 15 acres of forest free of ticks.   Every night they come home to roost in the chicken coop - except when the females get broody and decide to sit on nests in the forests next to fox dens, fisher cat holes, and coyote hunting trails.   Needless to say, there is a high mortality rate for broody hens that stay out overnight and we've lost 4 birds this season.  Unless we keep the guineas penned 24 hours a day (which would be cruel), there will be attrition.   By collecting the eggs from forest nests, we'll be able to keep our guinea population stable.    Since the eggs we gather from the forest are of an unknown age and fertility, we'll likely see a 50% hatch rate and an 80% 4 week survival rate for the chicks.   Although adult guineas are much more robust than chickens, the chicks are very fragile.    So 63*.5*.8 means that a few weeks from now we'll have 25 more guineas running around the farm yard.  Transforming eggs from the forest to birds in the barnyard is definitely a learning experience for us and I'll report back on our success rate.

The August HIT Council Meeting

On Monday, the HIT Council met to review progress on health information exchange in Massachusetts.   Here's the presentation we used.

You'll see that we've sent 1,349,083 transactions through the MassHIway.

Increasingly we're seeing subnetworks - aggregations of clinicians in regions of the state - joining the MassHIway to send transactions to other subnetworks.  We've heard presentations from our colleagues in Holyoke and the Pioneer Valley, both of which have created exchanges specific to their clinical service areas.   Our network of network vision is becoming a reality very quickly.

We're guided by a simple policy goal - to demonstrate measurable improvements in care quality, population health, and cost containment through use of health information technology

We're using grants to motivate stakeholders by:

-Encouraging vendor development of Direct-complaint interfaces, initiated within the workflow of their applications  and that will enable use of the Mass HIway by Massachusetts’ providers
-Accelerate connections to the Mass HIway
-Grow transaction volume

Major vendors such as Meditech are in testing and major providers such as Partners and Childrens will go live soon.

BIDMC is sending thousands of transactions per day to registries, providers, payers, and public health.   We're working with several grantees to expand the number and type of transactions including routing to patients/PHRs directly.

Our next major milestone is MassHIway Phase II which includes a master patient index and relationship locator service for "pulling" data with patient consent in an emergency.

So far, we're on time, on budget and making rapid progress with the MassHIWay.  It's great to see sustainable HIE supported by the community and demanded as part of accountable care operations.

Thank You Farzad

This morning, National HIT Coordinator Farzad Mostashari resigned.   His letter to ONC staff was profound.   As I read it, I felt a lump in my throat.   He will be missed.

How much do I respect him?   I have not worn a tie since Y2K, except for a bow tie last year in honor of Farzad.

I started working with Farzad when he served at the New York City Department of Health and Mental Hygiene as Assistant Commissioner for the Primary Care Information Project.   I was an early champion of eClinicalWorks and Farzad unilaterally transformed that product from a good EHR to a population health tool.

As Deputy National Coordinator he brought operational rigor and a public health perspective to ONC.

As National Coordinator he brought energy, enthusiasm, and momentum to healthcare IT.  He inspired, challenged, and influenced with informal authority, never a heavy hand.   Hundreds of people volunteered to support his vision out of respect for his ideas and a sense that it was the right thing to do.

Some people seek fame and fortune.   Some just want to make the world a better place.   In all the years I've worked with Farzad, I've never sensed any self-interest.   He has been mission driven.

Washington is a hard place to work.   Some say that no one is your friend (except your dog).    Hours are long, pay is poor, and travel is overwhelming.   Burn out is hard to avoid when you've cleaned the Augean Stables and your only feedback is that you missed a spot.

Each of the national coordinators had a different style.   David Brailer had the strong opinions that were necessary to establish a new federal office.   Rob Kolodner led early technology efforts at time when the Bush administration offered limited funding for healthcare IT.   David Blumenthal served as a noble statesman painting a vision for the HITECH program.   Farzad was the implementer who turned the HITECH vision into policy outcomes by pure strength of will.

I believe Farzad will serve until the end of September.   I'll do whatever I can to solidify the trajectory over the next two months so that the cadence of Farzad's strategic plan seamlessly transitions to the next national coordinator.

Building Unity Farm - Our Breeding Program

The small family farm is a physical and financial challenge.    We're not quite ready to offer our products commercially but after our first year, we've

harvested 240 ounces of honey
inoculated 200 Oyster Mushroom logs
inoculated 200 Shitake Mushroom logs
planted 180 high bush blueberry bushes
planted 30 heirloom apple trees
sheared/gathered fiber from 12 llamas and alpacas
gathered over 1000 eggs from our 12 chickens
raised 12 guinea fowl
split 10 cords of wood
fenced 2 acres for produce and prepared land for 18 raised beds in a hoop house

By next Spring we'll have products ready for sale but if we add up the value of everything we sell it will be less than $25,000/year.

Breeding animals is one way a small family farm can improve its sustainability.

After carefully considering the pedigrees of our alpaca, we elected to breed Midas (our 4 year old gold colored male pictured above) with Ella (our 7 year old experienced mother) and Persia (our 4 year old maiden).

After reading several books about Alpaca breeding we decided that a July 2013 breeding leading to a June 2014 birth would align well with good birthing weather in New England.   The gestation period of Alpacas and Llamas is 11 1/2 months and we really don't want labor to occur in the heat of August.

We moved Midas and Ella to our large pasture and left them alone for a few hours.   Then, we returned them to their paddocks.   The following day, we moved Midas and Persia to the pasture for a few hours.

We'll repeat the process this weekend.   Alpacas ovulate on demand - they are always capable of becoming pregnant.   We'll do a "spit test" for pregnancy in two weeks.   How do we do that?  After breeding, bring the pairs together.   If the female spits, kicks, and generally rejects the male, she is pregnant.  If she lies down and is ready to breed again, she is not pregnant.

Alpaca offspring are called crias and sell for $1500-$2500 on average.

We're also raising more Guinea Fowl this Summer.   We've gathered 25 fertile eggs from nests left in the forest and placed them in our incubator.   We keep the temperature at 99.5F and the humidity at 50%.   We use an automatic egg turner to rotate the eggs every 6 hours.   If we're successful, we'll have a new brood of guineas in 28 days and we'll raise them indoors for 12 weeks before moving them to the coop with the other adults.

Guineas are efficient tick and fly eaters, keeping our farm and yard free of biting and stinging insects.   They also alarm (by squawking) whenever a predator or trespasser threatens.    I would not recommend guineas for residential neighborhoods.   Guinea fowl offspring are called keets and sell for $5 each.

2013 has been the year of raising and breeding animals.  2014 will be the year that our produce efforts first become commercial.

Just as with the wine business, I'm sure we can make a small fortune in family farming, as long as we start with a large fortune.   More to come as I learn about the success of our breeding program and our overall economics.

Some Doctors Set Their Own Pay

The Centers for Medicare and Medicaid (CMS) sets the rates all physicians get paid and insurance companies base their rates on the same formula.  So who creates the formula?  Well, it's the doctors, silly!  Or at least some of the doctors.  Here's how it works:

A 31 member committee formed by the American Medical Association is made of of representatives from the various specialty societies.