Thursday, June 8, 2017

Building Unity Farm Sanctuary - Second Week of June 2017

Star the Donkey arrived at the Sanctuary last week and she’s living with the goats, serving as a livestock guardian.    She’s 18 years old  (donkeys live to 35) is about 100 pounds overweight.   We’ll be restricting her diet, giving her daily exercise, and provide intensive veterinary care until her weight normalizes.    I expect that will take a year or two.    Her first vet visit and farrier (hoof) work will be this week.


Honey the chicken develop wheezing this week and we’ve isolated her from the flock.   Although she has intermittent breathing issues, she’s eating, laying eggs, and acting normally.     We’re not sure if its viral, bacterial, parasitic, or structural, but we’ll continue to isolate and observe her.

Dr. Henry Feldman from BIDMC brought us an unusual gift this week - a laser cut holder for Unity Farm Cider and Honey Lager.   He made it on his Glowforge, a 3D laser printer.    The precision is amazing.   Here’s a video showing how it works.


Work on the sanctuary continues.   This week we replaced the toilets with modern low volume models from Toto so now we have highly reliable bathrooms for guests, visitors, and events.   We’re continuing work on the water system and all plumbing from well head to house distribution should be replaced by next week.

It’s been raining non-stop for the past week and we’ve been doing our best to keep the animals warm and dry.    Palmer the Turkey has learned to sleep indoors on rainy nights but most of all he loves his humans.



As the mud dries we’ll continue to add stone dust to the new paddocks and build fences.   By July we should be ready for the four new 12x20 run ins.

This weekend I’ll continue our Spring program of trail mowing and maintenance.   At this point, that means nearly 3 miles of work as listed below.     At the end of mowing 3 miles of trail, Ibuprofen is your best friend.


On the Unity Farm property, 6000 feet
Woodland trail 950 feet
Barn road 250 feet
Mushroom trail 250 feet
Orchard road 350 feet
Old Cart path 600 feet
Marsh trail 850 feet
Unity Lane 500 feet
Driveway 500 feet
Orchard trail 800 feet
Gate trail 450 feet
Forget me not glen  200 feet
Cattail hollow 50 feet
Momiji Matsu trail 250 feet

On the Sanctuary property,  2640 feet
Pine loop 600 feet
Pond trail  250 feet
Portion of Upper Meadow trail 400 feet
Coyote Run trail 400 feet
Treehouse trail 150 feet
Paddock trails (TBD) 840 feet

On the rural land foundation property, 5400 feet
Green Lane trail  1050 feet
Brook path 800 feet
Cattail loop  1800 feet
Lower Meadow trail 450 feet
Zions Lane 450 feet
Portion of Upper Meadow trail 850 feet

Wednesday, May 31, 2017

What’s Next for Electronic Health Records?

With the Department of Justice announcement of the $155 million dollar eClinicalWorks settlement (including personal liability for the CEO, CMO and COO), many stakeholders are wondering what’s next for EHRs.

Clearly the industry is in a state of transition.   eCW will be distracted by its 5 year corporate integrity agreement.    AthenaHealth will have to focus on the activist investors at Elliott Management   who now own 10% of the company and have a track record of changing management/preparing companies for sale.    As mergers and acquisitions result in more enterprise solutions, Epic (and to some extent Cerner) will displace other vendors in large healthcare systems.   However, the ongoing operational cost of these enterprise solutions will cause many to re-examine alternatives such as Meditech.

As an engineer, I select products and services based on requirements and not based on marketing materials, procurements by other local institutions, or the sentiment that “no one gets fired by buying vendor X”.

I have a sense that EHR requirements are changing and we’re in transition from EHR 1.0 to EHR 2.0.   Here’s what I’m experiencing:

1.  (Fewer government mandates) The era of prescriptive government regulation requiring specific EHR functionality is ending.   In my conversations with government (executive branch, legislative branch), providers/payers, and academia, I’ve heard over and over that it is better to focus on results achieved than to do something like count the number the CCDA documents sent via the Direct protocol.    If you want to use mobile devices to monitor patients in their homes - great!  If you want to use telemedicine to do wellness checks - great!  If you want to send off duty EMS workers using iPads to evaluate the activities of daily living for elderly patients  - great!  Reducing hospital readmissions is the goal and there are many enabling technologies.    Suggesting that one size fits all in every geography for every patient no longer works as we move from a data recording focus (EHR 1.0) to an outcomes focus (EHR 2.0)

2.  (Team-based care) Clinicians can no longer get through their day when the requirements are to see a patient every 15 minutes, enter 140 structured data elements, submit 40 quality measures, satisfy the patient, and never commit malpractice.  A team of people is needed to maintain health and a new generation of communication tools is needed to support clinical groupware.   This isn’t just HIPAA compliant messaging.   We need workflow integration, rules based escalation of messages, and routing based on time of day/location/schedules/urgency/licensure.  We need automated clinical documentation tools that record what each team member does and then requires a review/signoff by an accountable professional, not writing War and Peace from scratch until midnight (as is the current practice for many primary care clinicians)

3.  (Value-based purchasing) Fee for service is dying and is being replaced by alternative quality contracts based on risk sharing.

Dr. Allan H. Goroll’s excellent New England Journal of Medicine article notes that EHR 1.0 has achieved exactly the result that historical regulation has required - a tool that supports billing and government reporting - not clinician and patient satisfaction.

Our electronic tools for EHR 2.0  should include the functionality necessary to document care plans, variation from those plans, and outcomes reported from patient generated healthcare data.    Components of such software would include the elements that compromise the “Care Management Medical Record” - enrolling patients in protocols based on signs/symptoms/diagnosis, then using customer relationship management concepts to ensure patients receive the services recommended.

ICD-10, CPT, and HCPCS would no longer be necessary.    Bills will no longer be generated.   Payments would be fixed per patient per year and all care team members would be judged on wellness achieved for total medical expense incurred.   SNOMED-CT would be the vocabulary used to record clinical observations for quality measurement.

4. (Usability)  I do not fault EHR developers for the lack of usability in medical software.  They were given thousands of pages of regulations then told to author new software, certify it, and deploy it in 18 months.   I call this the “ask 9 women to have a baby in 1 month” concept, since Meaningful Use timeframes violated the “gestation period” for innovation.   How can we achieve better usability in the future?   My view is that EHRs are platforms (think iPhone) and legions of entrepreneurs creating add on functionality author the apps that run on that platform.  Every week, I work with young people creating the next generation of highly usable clinical functionality that improves usability.     They need to be empowered to get/put data from EHR platforms and emerging FHIR standards will help with that.  

I was recently asked to define HIT innovation.  I said it was the novel application of people, processes and technologies to improve quality, safety and efficiency.    Creating modules that layer on top of existing EHR transactional systems embraces this definition.

5.  (Consumer driven)  In a recent keynote, I joked that my medical school training (30 years ago) in customer service mirrored that provided by the US domestic airlines.   Healthcare experiences can be like boarding a crowded aircraft where your presence is considered an inconvenience to the staff.    We’re entering a new era with evolving  models that are moving care to the home including internet of things monitoring, supporting convenient ambulatory locations near you,  offering urgent care clinics with long hours, enabling electronic self scheduling, and encouraging virtual visits.    Although existing EHR 1.0 products have patient portals, they have not made the patient/family an equal member of the care team, providing them with care navigation tools.  BIDMC is working on an Amazon Echo/Alexa service backed by microservices/Bots that brings ambient listening technologies to the home for coordination with care teams.  When see you articles like this one, you know that the technology tools we have to support patients as consumers are not yet sufficient.


The US has been working on EHR 1.0 for a long time.   57 years ago, the New England Deaconess computerized its pharmacy using an IBM Mainframe.  Here’s the original document from 1960 describing the achievement.   Of note, the document highlights that the overall hospital budget reached a new high - $5.4 million and the increased salary, clinical care and IT expense meant that hospital rates would have to be raised to $25/bed/day.     After nearly six decades of work on EHR 1.0, let’s declare victory and move onto social networking-like groupware supporting teams of caregivers focused on value while treating patients as customers using mobile and ambient listening tools.  Government and private payers need to align incentives to support this future based on outcomes, putting the era of prescriptive EHR 1.0 functionality (and the energy enforcing the regulations) behind us.

Thursday, May 25, 2017

Building Unity Farm Sanctuary - 4th week of May 2017

Spring’s warmth and rain is accelerating our plant and mushroom growth such that every day is a balance between  agricultural management and sanctuary development activities like trail building as pictured below.   The stone bridge you see was built in the early 1800's.


The adventuresome project of last weekend was replacing the 20 year old heating oil tanks in the Sanctuary.   The seams were weeping and oil was accumulating on the sides of the tanks.   I recently heard a nightmarish story about an oil delivery of 500 gallons into a 250 gallon tank that had a newly ruptured seam.   With new tanks, we’ve avoided that risk.   The challenge is that the sanctuary has no basement - just a 4 foot crawl space.   To extract the old oil tanks we had to remove the staircase in the crawl space and lift the tanks to the first floor without spilling old oil or scratching the wood floors.    Not fun, but we were successful.

The other not fun project was replacing all the fiberglass insulation in the crawl space.   In the past, the roof gutters directed water immediately down the side of the building and into the basement causing annual flooding and mold.    We’ve redone the gutters to direct all water away from the foundation.  The crawl space has stayed completely dry this spring.   I pulled 200 linear feet of fiberglass insulation out from the crawlspace, bagging it to avoid dragging mold, mouse droppings and fiberglass through the building.    Lying on my back in the dirt of the crawlspace, I reapplied rolls of R19 insulation and a vapor barrier.   I wore goggles, a mask and full body loose fitting clothing, minimizing fiberglass misery.

While doing the fiberglass project I found a few more hundred feet of old wiring and rusted electrical boxes.   At this point, the only wires in the entire crawlspace are active electrical lines, fire detection sensors, and internet fiber.   Victory!

The next great archeological challenge will be replacing the entire water system and all the plumbing in the crawlspace.   At the moment the plumbing is like the city of troy - built in layers.   What needs to be done?  I’ll take a sawzall at the input pipe from the well and at the main distribution for the building, removing everything in between - a maze of copper and valves installed 1959-1995.    Much of our work on the sanctuary is not about adding infrastructure, it’s about removing 50+ years of infrastructure layers.    The only water system that is needed is a simple pressure tank with a small debris filter directly connected to the house and paddocks.    No water treatment, softeners, or iron removal are needed, massively reducing complexity.   There’s no need for segregated filtered and unfiltered plumbing.  The water test shows that the well is perfect - 10 gallons per minute of sterile, iron free water, so we’ll go from a deep underground stream to house and animals without anything in between.



As unexciting as it sounds, we’ll also be replacing the toilets which date from 1960 to 1990.     In the early 1990s toilets went from high flow to low flow and the models from that era are incredibly unreliable.   Given that the sanctuary is a public space, having a plunger in every room is not the right solution.   Toto toilets will be in place by June.

In the mid 1990s a carriage house/workshop for storage and vehicles was built on the sanctuary property but it was never finished.    There were live electrical wires hanging from the ceiling, walls were primed but never painted, and the fire/smoke alarms were disconnected.     I’ve redone all the electrical/lighting, connected fully wired fire/smoke alarms to the main house by running cable through an underground conduit, and begun the process of wall/ceiling finish work.    The carriage house will become our honey processing area and serve as one of our teaching areas for beekeeping, beer making, and mushroom cultivation.    By July it should be finished to perfection.

This week, the stone dust necessary to finish the paddocks arrives.  How much do we need?  The paddocks are a trapezoid 300 feet on one side, 225 on the other side and 200 feet wide.  If you remember your geometry, the area is (300+225)/2*200=52500 square feet.  Just how much stone dust will cover 52,500 square feet at 3 inches thick (recommended for horses) - just go to this website and you’ll discover we need 700 tons i.e. 1.5 million pounds.    The first 200 tons arrived yesterday.

Once the stone dust is placed, the fencing goes in and by mid June we’ll have four quarter acre paddocks for new rescues.  As soon as its done, I’ll post pictures.

By the time the Summer gives way to Fall, the building of the sanctuary should be complete and my blog posts can return to the joys of running a farm and sanctuary, since maintaining is much easier than creating.

Thursday, May 18, 2017

Building Unity Farm Sanctuary - Third Week of May 2017

In case it seems that my posting frequency has dropped, it’s a combination of a hectic spring farming/sanctuary schedule and writing requests from outside organizations.   For my views on the recent cybersecurity/ransomware events see the PBS Newshour blog.

Unity Farm Sanctuary work clothes have arrived in our closets.   This was my wife’s idea to identify mentors and experienced volunteers on the property.   We have so many visitors every day who are walking the trails, visiting the animals, and offering to help that we need to separate those with experience from those who are new to the sanctuary.    The shirts make it easy to find someone knowledgeable.


Our 501(c)(3) charitable designation should be approved soon, but in the meantime, we're receiving donations of equipment and items considered useful for the sanctuary.   For example, this 1800’s wheelbarrow seemed just the right tool for an 1833 meeting house.  It was dropped off earlier this week.    Some has just donated a canoe for sanctuary visitors who want to explore the upper marshes of the Charles River which has a canoe put in a few minutes drive from the sanctuary.



Later this week, another Welsh Pony,  named Grace will arrive at the Sanctuary.   We’re building new paddocks as fast as we can but they will not be ready until the end of June/early July.     Grace will live with the goats in the short term.   The goat paddock has two run ins so the pony can have a private space.

The process of creating 2 acres of new paddocks that are safe for horses takes diligence.   First, we cleared brush and leveled out the land.  Then we applied a layer of “tailings” rocks and dirt that provide a layer of drainage.   Then “stone dust” provides the finished surface which is solid and smooth but still promotes drainage.   Once that is done, we’re adding some additional fencing and gates so that we can easily bring in food and remove manure.    Then we add south-facing run in buildings to protect the animals from inclement weather.   Finally, we trench for electrical and water supplies to each building.   I’ll be doing all the electrical and plumbing, so we keep expenses to a minimum.   When completed, the 4 new paddocks, each about a half acre, will enable us to take on a few more creatures that need rescuing such as a donkey and a few sheep that we were recently told need a new home.   We’re very careful to take on new animal responsibilities selectively so that we can provide each the daily attention it needs.  As I’ve said before, we provide “forever homes” and thus we need to budget our time and resources for the long term support of any animal that arrives.

Next week, a “rafter” of turkeys arrives at the sanctuary, which will provide an instant family for Palmer, our Royal Palm tom turkey.   Palmer is extremely social and follows humans on long walks into the woods.   It will be fascinating to see how he adapts to young poults.    Thus far, the 20 wild turkeys at the sanctuary do not interact much with Palmer, although they call to each other in the night.

The work on the sanctuary buildings continue and last weekend I removed all the obsolete electrical circuitry from the 1960’s.   The 1833 Sanctuary building was moved to its current site in 1959 and the area underneath is only 3 feet high because of all the unmovable ledge rocks at the site that prevented digging a full basement.   I found numerous open electrical boxes with exposed wiring in the crawlspace that looked a bit dangerous for anyone doing work on heaters, plumbing or other under building infrastructure.   I carefully traced every wire and found that they were unconnected at both ends - just hundreds of feet of old cable and numerous electrical boxes with no purpose whatsoever.    I removed everything.   The good news is that neither the building’s electrical system nor my body was harmed in the process, although I did emerge from the crawlspace covered with mud, cobwebs, and decades of accumulated dust.    I also removed old thermostat wires, door bell wires, and phone lines that have not been used in decades.    I’m fairly confident that the work I’ve done thus far under the building - removing about half a mile of old wiring - is now done.   Maybe I’ll never have to spend another weekend day crawling under the building.    Luckily Claustrophobia and Arachnophobia are not issues for me.


This weekend will include the usual extra time with the animals, providing them companionship and extra exercise plus the tasks of spring - mushroom inoculation, planting warm weather seedlings (cucumbers/peppers/tomatoes).   All of the apple trees are in bloom, all of the hoop house vegetables are thriving, and the mushroom logs are fruiting.   2017 should be a bumper crop.

Thursday, May 4, 2017

Building Unity Farm Sanctuary - First Week of May 2017

We continue to work on the forests and trails surrounding the Unity property to create a community resource.

 The map below shows the current status of the land (water is in blue) - 18 trails, 10 bridges, 3 ponds, and 5 streams.   We’re clearing invasive non-native plants, removing decades of scrap metal/pottery/plastic midden piles, and taken down unstable dead trees that are a safety issue.  With every passing week, the land becomes more and more accessible.  Every time I go to the rural foundation meadow, I find it filled with wild turkeys, deer, raptors, coyotes, and rabbits.   Our goal is to protect the local natural ecosystems while also offering educational opportunities to the community.   The cattail loop and brook path are the new trails we built this week.   All the remains to be done is spreading wood chips on all the new trails, which we’ll do over the next few months.  Well,  I do have to clear one fallen oak tree on the brook path that's 8 feet in circumference (pictured below).   I need a bigger chain saw!




On Saturday, with town permission,  I cleared all the fallen trees and overgrowth from the Sherborn portion of the Bay Circuit Trail (the complete trail runs from Newburyport to Duxbury - 200 miles).   The portion of trail I have volunteered to maintain is the 4 miles between Perry Street and Route 27.   This seldomly used trail is just a few minutes from the Unity trails and has a great wilderness feel to it.   After a few hours with chainsaw and hedge trimmers, the trail is in great shape.

The warmth of spring has brought an early crop of flies and we’ve implemented our usual prevention measures - organic/pesticide-free fly traps,  fly tapes in the barn, and 20000 fly predator wasps (they don’t sting).   We have fly masks for the horses if needed, but thus far we’re keeping the fly problem at bay.

The produce from the farm this time of year includes asparagus, mushrooms, and eggs.  The longer days mean that all hens are laying and I delivered 22 dozen eggs to Tilly and Salvy’s farmstand last night.   I’m picking daily fresh asparagus and just harvested 20 pounds of Shiitake mushrooms.    Soon, our spring greens will be ready in the hoophouse and they’ll be replaced with cucumber, tomato, and pepper transplants, which are growing in the greenhouse now.

The weekend ahead includes the usual farm and sanctuary related tasks - animal care, repairs, planting, wood cutting, and trail mulching.   As stewards of 150 animals and 60 acres, the joyful work is never done.

Thursday, April 27, 2017

Building Unity Farm Sanctuary - Fifth Week of April 2017

Several folks have contacted me, wondering why the pace of my blog posting has slowed a bit in April.    Don’t worry - all is well on the farm and sanctuary, it’s just spring planting, maintenance, and trail building time.    The snow has melted, the weather is mild and the plants/animals need more attention that ever.

Here’s what we’ve been up to over the past two weeks.   The adjacent landowner to Unity Farm and Sanctuary is the Sherborn Rural Land Foundation and they’ve asked for our help maintaining their protected land.   I’ve expanded our trail system to cover 60 acres with over 3 miles of paths as pictured below.    We now have  18 trails and 8 bridges that traverse through ecosystems ranging from dry oak to wildflower meadow to fern grottos.   Each bridge weighs about 500 pounds, so hauling all that lumber into the forest means that I walk about 15 miles per weekend day.



The new paths (in the black square box below)) enable us to connect to the Bay Circuit trail  (in red below)- a 200 mile  path from Newburyport, MA in the north to Duxbury, MA in the south.    It’s fair to say that Unity Farm and Sanctuary paths enable 100 mile walks in each direction!


Part of maintaining wild forests is removing a century of garbage that others have thoughtlessly dumped there.    I removed over a ton of debris from the farm forests and a ton of debris from the sanctuary property.    I removed a similar amount of old furniture, plastic and metal from the Rural Land Foundation property.     I definitely got my exercise hauling everything from the forest to a golf cart parked on a nearby road.


Part of the Rural Land Foundation property is a 5 acre meadow.  We gently raked the land and spread native wildflower seeds over the area.   We’ll have significant rain this week, so hopefully the new sprouts will get a healthy start.   Kathy will likely add new bee hives to the meadow this Summer.


All of the animals continue to thrive and they are enjoying the warmth of spring.   The pigs want their daily massages and demand our attention.   Here’s what rolling in the hay with pigs looks like.


We’re continuing our work on paddocks, fences, and run ins.   By Summer I’ll post pictures of the finished result - interconnected space for horses, donkeys, pigs, goats, cows, llama/alpacas, poultry and other animals that need sanctuary space.  We’ve lived at the farm for 5 years as of today.    Who would have guessed 5 years ago that we would have so many vibrant activities around us every week.

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

Horses/ponies
Goats
Sheep
Cows
Alpaca/llama
Chickens
Ducks
Geese
Guinea Fowl
Turkeys
Donkeys
Pigs
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.