Thursday, August 18, 2016

Unity Farm Journal - Third Week of August 2016

I’m on “vacation” this week, working remotely from the farm, so no Wednesday blog post, but here’s the Unity Farm update.

I always tell my staff that management is balancing scope, time and resources.    Too much scope and not enough makes resources very grouchy unless they are augmented.

The same thing is true about managing a farm.   Unless you set a scope that is achievable with the resources you have, the time (defined as the seasons in the farming year), living things, including your own well being, will suffer.

As we plan for 2017, something we’re doing during my slack time this week, we’e set a scope that we believe is achievable with two people (Kathy and me), taking into account our responsibilities to family members, work life, and finances.

*beekeeping (scope = 100 hives, about a million bees, processing 2500 pounds of honey/year)  with a motorized 20 frame extractor, electric wax melter, mobile uncapping table, and bottling tank
*poultry (scope = 100 chickens of various ages, processing 500 dozen eggs/year)

*craft cider (scope = 250 gallons as limited by the production of Unity Farm orchards - about 6000 pounds of apples per year) with a 36L press, a motorized grinder, food grade fermenters
*honey lager (scope = 250 gallons requiring 170 pounds of Kathy’s honey) using 20 gallon stainless steel boiling pots and food grade fermenters
*compost (scope = 10 tons per year, screened and bagged with the custom motorized equipment we built)
*alpaca (scope =5 males and 8 females and 1 guard llama) producing fiber that we spin into yarn
*pigs (scope =1 male and 1 female) eating all the fruits/vegetables that we cannot sell to humans

Kathy and John
*Vegetables (scope = 50x21 foot hoop house and 6 outdoor raised beds growing
Late fall to early spring: optima pelleted lettuce, napoli pelleted carrots, bloomsdale spinach, touchstone gold beets, rainbow chard, garlic
Spring to early fall: marketmore cucumbers, shishito peppers, heirloom tomatoes, japanese eggplant, mold resistant basil, jacobs cattle beans
Cover crops field peas, buckwheat, clover
*Shiitake mushrooms (scope = 500 logs producing 1000 pounds of mushrooms/year innocuated with our self built mushroom processing stand)
*Fruit (scope = 2 acres of Strawberries/Raspberries/blueberries in 3 netted enclosures)

As I’ve said before, farming is like gardening, just at a larger scope.   To put it in perspective, here’s what today’s tomato harvest looks like.  

We’re doing daily deliveries to the farmstand of basil, tomatoes, eggplant, eggs, and peppers.    We’ve spun our summer honey and will start to deliver that soon.

Luckily the blazing temperatures of early August are beginning to wane and the animals are much more comfortable.   Cold weather is just around the corner and they’ll all be healthy heading into the hard months ahead.

Thursday, August 11, 2016

Unity Farm Journal Second Week of August 2016

Running an organic farm means that you have to manage animals and plants in concert with the trials and tribulations nature throws in your path.  You must become an expert on predator/prey, disease/cure, and seasonal variation.  How do you deal with wet/dry, hot/cold, light/dark, insects/rodents, planting/harvesting rhythms etc.

For example we know that flea beetles, which eat eggplant leaves die in July.   Thus we raise eggplant seedlings indoors and plant them in July.

We know what tomato hornworm damage looks like so we can rapidly find the hot dog sized caterpillars and feed them to the chickens.

This week’s issue is black sooty mold on the basil.   Earlier in the season we had aphids on the young tomato plants.   The aphids, by drilling into plant tissues, created a layer of “honeydew” on the leaves that was infected by mold.   That mold spread to the nearby basil and some of the leaves are yellowing.   Our approach has been to spray a very dilute organic sulfur solution (.4%, OMRI certified) on the undersides of the basil leaves, which kills the mold.   When we harvest the leaves, we carefully remove any damage and wash the remaining plants so they are perfect.  Greenhouses and hoop houses can be very humid and shield plants from drying breezes, so it’s clear we need to step up our hoop house airflow to reduce mold problems in the future.

We’re also struggling a bit with cucumber beetle - they disrupt the vascular system of plants and stunt the growth of cucumbers.     We’re spraying with a soap solution every 3 days, but it may be a losing battle.   Our early cucumber harvest was plentiful but this weekend I may remove the cucumbers and replace them with the bibb lettuce we’ve germinated.    For the moment, frogs have moved under the cucumbers to snack on the beetles.

We continue to have many predator visits because of the hot dry conditions we’ve been experiencing this summer.   The coyotes visit every night and the livestock guardian dogs are working overtime to keep them away.    A few of our chickens are solitary wanderers during the day and we’ve lost a few to coyotes/foxes.    Yesterday we did receive .25 inch of rain, so at least the top of the soil is moist.

Our well produces 6 gallons per minute and we’ve been stretching that over our 60 irrigation zones to keep all the orchards alive, but its a struggle.   Just about every town around Boston has a mandatory water ban and even properties with wells are being asked to conserve ground water.    And I thought the Northeast would be a refuge from the drying of the West and Southwest.     Time to take a closer look at Canada…

Over the next two weeks, I’m going to try to work from the farm as a kind of “staycation”   There’s Fall planting, record keeping, and maintenance to do.    There are living things to nuture and extra young guinea fowl to place at nearby farms, as pictured below.   Before the post labor day craziness starts, I’ll do my best to recharge my batteries and get the farm ready for the harvest season ahead.

Wednesday, August 10, 2016

A Visit to Oscar Health

Today I’m in New York City visiting Oscar Health, on my continuing quest to determine how best to integrate digital platforms, patient-family engagement, and care coordination in preparation for MACRA/MIPS and the transformation from fee for service to alternative payment models.

At the moment, there is no single magic bullet, but there are early innovations that hold promise.

At BIDMC we’ve thought the best approach to care management is to identify a cohort with a disease, then enroll that cohort in a program which involves tracking progress against guidelines/protocols, deploying telemedicine/visiting nurses, and measuring data from home-based devices.

Oscar’s approach incorporates similar ideas by providing a unique mobile app and web resources for patients, providers and care managers, reducing total medical expense through informed care navigation.  For example, you are given a choice of options based on your signs/symptoms that aligns the intensity of the service with the intensity of the illness.  Care is coordinated via sharing of clinical and claims data among care teams.   Episodes of care are tracked to ensure patients follow a coherent path.   The technology is superb and the staff is creative.  I hope their startup phase evolves into a long term sustainable business model.

Other interesting technologies to watch are the Salesforce Health Cloud which brings customer relationship management techniques to the caregiver/patient relationship.   Isn’t it ironic that the Ritz Carlton can remember your pillow preferences but your clinician’s office hands you a clip board at each visit to answer the same questions over and over?   Today’s EHRs were designed for documenting episodes of sickness, not encouraging wellness.    The concept of customer relationship management in healthcare is what I call “Care Traffic Control” - setting goals for the patient then ensuring those  goals are tracked, reviewed and discussed.

Apple's CareKit  is another technology to follow since it enables care planning, care team communications, and care progress monitoring all on your phone.    BIDMC is launching its first CareKit app when iOS10 is released this Fall.   The app - a version of BIDMC@Home that includes HealthKit, CareKit and BIDMC Patientsite features all in one platform, is something I believe will bring true value to patients and families.

The next two years in healthcare will be rocky - the end of Meaningful Use, the transition of presidential administrations and the release of final rules from CMS that will shape reimbursement for the next 5 years.     The winners will be those health systems that respond to these disruptions with agility.    The time to begin selecting the tools you’ll need to manage wellness, control medical expenses, and treat patients as customers is now.

Thursday, August 4, 2016

Unity Farm Journal - First Week of August 2016

The farm refrigerator is 25 years old and this weekend it finally failed.   It had two working temperatures - too hot and too cold.    After 25 years of hard work it had to be retired, since spare parts are no longer available.   The new refrigerator arrived today and our cold chain is up and running again.

Tomatoes and peppers are plentiful - here’s what one morning’s harvest looks like.

All our tomatoes are heirlooms, grown organically.   For example, we do slug control on the Cherokee Purples by placing bowls of beer in the bed to attract pests and keep them away from the tomatoes.    The slugs have a preference for Sam Adams.    The only spraying I did all season was a light soap solution (OMRI listed) to control aphids.      We’re doing farm stand deliveries to Tilly and Salvey’s in Natck every 2 days because demand for fresh tomatoes and basil is high.

Fall is just a few weeks away so we are getting ready.   We grind all our old mushroom logs into mulch for the 1.5 miles of trails on the farm.    As I’ve said before, farming is just like gardening, but at a larger scale.   Here’s what the freshly ground mulch pile looks like - about 5 tons ready to spread on the trails.

The young guineas and chickens continue to learn their way around the farm  - exploring every ecosystem.  They seem to prefer to cool forest undergrowth immediately adjacent to the barnyard where they are protected by the geese and roosters.

Our meadow is filled with wild turkey babies - about 20 of them.   They love the tall grass.    Three moms are protecting the young turkeys that range in size from baseball to basketball height.

We’ve had some rain this week - about .3 inch.    The drought is still upon us, but at least the ground is moist and the trees are less stressed.

This week I finished the two year Umass Certificate program in organic farming.   Since it’s my 7th academic credential, my wife has declared that I’m in 37th grade.
As I wrote in yesterday’s post, learning never stops.

This weekend will be filled with vegetable harvesting including our Jacob’s cattle beans, trail maintenance, and planting Fall seedlings.   Although it’s August, I can tell the days are getting shorter and we’re getting closer to the change of pace that occurs every year post labor day.   I always look forward to the change of seasons and the cool days ahead.   The pigs are not quite sure since they asked to be tucked under their blankets last night after the 60F chill of dusk

Wednesday, August 3, 2016

My Guiding Principles

As I’ve aged and matured my approach to life, career, and family, I’ve evolved my rubric for organizing each day.    Here’s what I’ve used for 2016

*Minimize lost time
Avoid commuting delays as much as possible - leave no later than 6:00am in the morning and return either before 3pm or after 7pm.   I generally go in early, return early, care for animals, then work in the evening.    I work in Boston Tuesday/Thursday, in our suburban Metrowest office Monday/Wednesday and wherever the most urgent projects are happening on Friday.

Limit airline travel to impactful events - I have numerous federal/regional/state commitments and used to fly to every one.    Now I assess the impact of the meeting and limit travel to one day a month.    This Fall has an unusual cluster of international travel - Denmark, New Zealand, and Israel, all related to collaborations around interoperability and security.

 Be virtual whenever possible - Although high intensity meetings are best attended in person, standing meetings with people you already know can be done effectively by phone.    A one hour phone meeting is a much better use of time than a one hour commute, a one hour meeting and another one hour commute.

*Do satisfying activities that make a difference each day - doing a job you love is directly related to happiness, longevity, and domestic tranquility.  

*Family comes first - careers can be changed, but family is forever. To keep my family members happy and healthy, I must help my daughter establish a self reliant future, help my wife achieve her goals, and ensure my mother (the last surviving parent) can do fulfilling activities in a stress free living environment

*Be Well - personal health directly impacts my performance in all aspects of life.   Each day includes at least an hour of exercise (generally related to farm activities) and sound nutrition (vegan for 20 years).   I strive to improve life processes, fixing whatever is broken, be that a machine, a schedule, or a relationship.    I never stop learning and experimentation.

*It Takes a Village - there are too many tasks in too little time to do them all yourself.    It’s important to share burdens, whatever they may be.   None of us are an island and we need to constantly learn from others.    Regardless of what happens each day, there is a process for everything to get to a better place.

Those 5 principles have worked me in 2016.   No doubt, 2017 will refine this further.  I never know what tomorrow will bring, but I’m confident each day will be better than the last.

Thursday, July 28, 2016

Unity Farm Journal - Fifth Week of July 2016

Have you ever heard the expression, “Sweating like a pig” when someone is sweating profusely?

It’s a particularly strange statement since pigs don’t sweat much.   They have sweat glands but they are not effective, so pigs wallow in mud to keep cool.

This week in Massachusetts every day has been in the mid 90’s with heat indexes about 100F.   It’s been miserable.

Hazel Marie, our 200 pound pig, has never liked getting wet.   Before we adopted her, she lived indoors and never experienced the hot of Summer of the cold of Winter.

This week, she learned the joys of cooling off.   I started giving her cool water sponge baths, which she tolerated but did not really enjoy.    We set out a cool spray and she stood a few feet away, taking in the mist but not relishing the full stream.

Yesterday, she decided that water was her friend and now can’t get enough.   She begs us to spray her, rolls in the full stream, loving her baths.     Clearly my next farm invention needs to be a snout actuated pig shower.    Tofu, our smaller pig, still prefers his mud.

Every month on the farm has its focus.   July is a month of harvesting basil, cucumbers, peppers, blueberries, garlic, and honey.  

Farming just like gardening but on a larger scale.  Here’s what a honey tank looks like after spining a few frames.

We continue to scale up all aspects of our honey production - wax melting, spinning, settling, and bottling.

This week we let all the young guineas and chickens out of their mini-coops so they are now free ranging.   Given the hot, dry weather, we’re watching them closely since our predator load is high - there’s not much to eat in the forest at the moment, so young birds are very tempting.

Much of our evening and weekend time is spent keeping our creatures cool and hydrated.   The good news is that temperatures will drop to a comfortable 80 degrees on Friday.   We’ll continue to pray for rain!

Wednesday, July 27, 2016

The Rise of Telemedicine

As reimbursement evolves from fee for service to alternative payment models, incentives will shift from treating sickness to keeping the population healthy.   New investments will be made in technologies that reach into the home and enhance care team communication.     2016 saw an acceleration of telemedicine/telehealth.   2017 will see exponential growth.

Telemedicine is hard to define.   It could be real time video teleconferencing between clinicians (a consult), between a patient and clincian (a visit), or group to group  (tumor board discussion).    It could be the transmission of a static photograph, such as the poisonous mushroom/plant teleconsultation I do 900 times per year.    It could be secure texting to coordinate patient care.

Patients might provide care teams with objective data from devices in their homes.  Patients might answer surveys about their mood, activity, or pain.

All of these are telemedicine.

Many companies will offer cloud-based tools and technologies to support these new workflows.   Some organizations will  use bridging technology to link together every kind of endpoint (Skype, Facetime, commerical telemedicine apps) with every kind of endpoint.

There are so many use cases and so many possibilities that one approach will not serve all needs, so most organizations will have a multi-faceted strategy.

There are some unanswered questions

1.  How do you bill for telemedicine?  There is a new CPT code, but it’s not clear how it should be used.

2.  How do you address multiple conflicting state laws when consulting across borders?

3.  How is the record of a virtual encounter stored and who is the steward of the record?

For my personal telemedicine practice, toxicology consultation, I use an iPhone and email to review cases and images.   No protected healthcare information is exchanged.

I am credentialed by BIDMC for telemedicine practice

I am malpractice insured for telemedicine practice.

When consulting across state lines, I provide advice to licensed physicians in that state and never interact with patients directly (or prescribe).

I do not bill for these services, they are a public good.

Medical records are kept by the physician consulting me and that physician is the steward of the record.

As hospitals expand to serve patients at the national and international level, as payment models require more home care/wellness care, and as consumers demand the same kind of convenience  from healthcare that they get from other industries, telemedicine will expand and mature.

Telemedicine at BIDMC (part of Media Services) reports to me and I’ve requested additional staffing and investment for 2017.    Technology, business needs, and customer demand are aligning to make telemedicine an increasingly important service offering for clincians and hospitals.