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.