Wednesday, October 25, 2017

Don't Let Things Slip Away From You

Kathy has written this guest post, about the unexpected death of a friend.


"Please don’t let things slip away from you:
first steps,
first kiss,
first real vacation…
first time you know that something is not quite right in your body.

I discovered yesterday that someone about my age whom I have known for at least 15 years had passed away in September. I had seen her once during the summer.

I was told by her colleague that about a year and a half ago, she noticed leaking from one breast. Her coworkers persisted in asking about the situation and she then told them it was just an infection from a cat scratch. It is not clear she ever sought any medical care at that point.

Fast forward to this summer: she developed pneumonia and liver failure, consequently was hospitalized, and all the way to the end she did not acknowledge that the test results showed widespread metastatic breast cancer.

Speaking as a breast cancer patient past my 5 year mark post treatment, none of it was fun or easy, but I bless every day I am given to enjoy my life and family. I think I was so floored by the discovery that my acquaintance had died in a state (MA) where we have had mandatory health insurance for a long time. I have lost other friends to breast cancer, one dying after it infiltrated her brain, but she could never afford health care as a self-employed artist in the era before mandatory health insurance. I know she spent about two years convincing herself nothing was wrong too - until it was too late to do anything.

My father “toughed it out” as he lost weight and grew fatigued. By the time I realized how many pant sizes he had dropped, the neuroendocrine tumor on the head of his pancreas was untreatable. I daily feel robbed of his smile, I am only reassured knowing that he passed so quickly after diagnosis that he never had much time where he was incapacitated.

All this leads to express my hope that if you know something is not quite right in your body, face the risk of getting a diagnosis even when you don’t want to hear the news. Your family and friends want to know you for as long as they can. And cancer therapies and treatments are making amazing advances - while there is life there is hope."

Saturday, September 16, 2017

Building Unity Farm Sanctuary - September 2017

I’m on a flight to New Zealand as part of my international government service.  The 26 hour commute means that even with just two days of meetings in Auckland, I will be gone from the farm for 5 days.

I spent Saturday morning cleaning paddocks, emptying manure carts, packing hay bins, filling water troughs, and doing the final repairs/maintenance that will ensure the farm/sanctuary can thrive for a few days while I’m gone.

 What happens at the sanctuary over a typical week?

 Numerous volunteers spend time with animals, providing companionship, exercise and socialization


Horse experts bond with Amber, Milly, Grace, and Sweetie, showing them love, respect, and skill as they build enough trust to ride them.   Star our donkey has dedicated volunteers that cherish their time with her, and give her the attention she loves, and the exercise with walks that she needs. Donors bring us saddles, bridles, medicine, blankets, and food to keep the horses healthy.



Our friends and colleagues help us create safe living spaces for our animals.   Here’s what our equine rescue area looks like today with 8 stall spaces,  an acre of paddock supported with heat, power, light, water, and a medical treatment area.



Our agriculture volunteers are helping with apple picking, mushroom log inoculation and harvest.   We picked 40 pounds of Shiitake this week.   Our 36 different varieties of apples are approaching that perfect picking moment.  How do we know?  We measure the starch and sugar levels of each tree to decide when to pick.    Here’s a great article about the process.



 New babies are born every week.   Two proud guinea parents brought us a dozen new children which we’re caring for in our brooders.



Just before I left I completed the organic certification for 2017, which is  very similar to a Joint Commission visit.   The inspector reviewed our entire operation, our record keeping, and our policies.   In 2017, we should achieve organic certification for our fruits, vegetables, honey, mushrooms, and compost.

We’re getting very close to completing our Sanctuary building phase - the electrical, plumbing, heating, windows/doors, painting, well systems, irrigation, and gutters/downspouts and fireplaces have all been fixed/maintained.    The last project before winter is the generator - a 20kw Generac to ensure the animals have water, light and heat even if winter storms knock out power.

2017 has been an amazing time - a faster pace of change, projects, and activities than Kathy and I every thought possible.  As we transition into Fall, we can say with confidence that the 200+ animals at Unity Farm Sanctuary are healthy, supported, and loved.   That’s all we could ask for.

Now you know why Kathy and I can never travel together away from the sanctuary.   While I’m in New Zealand, she’s running the enterprise.   The good news is that we have traveled the world together from 1980 to 2010.   At this point, we’re completely comfortable dedicating our lives to our sanctuary work.

Thanks so much to our volunteers, Board of Directors, and community for making it happen.



Tuesday, September 12, 2017

We Can Improve Care Management

As a physician and CIO, I’m quick to spot inefficiencies in healthcare workflow.  More importantly, as the care navigator for my family, I have extensive firsthand experience with patient facing processes.

My wife’s cancer treatment, my father’s end of life care, and my own recent primary hypertension diagnosis taught me how we can do better.

Last week, when my wife received a rejection in coverage letter from Harvard Pilgrim/Caremark, it highlighted the imperative we have to improve care management workflow in the US.

Since completing her estrogen positive, progesterone positive, HER2 negative breast cancer treatment in 2012 (chemotherapy, surgery, radiation), she’s been maintained on depot lupron and tamoxifen to suppress estrogen.   After three years on a protocol of 22.5mg of lupron every 3 months, her insurer and pharmacy benefits manager decided that 11.25mg was an equally effective dose and sent her a letter telling her they would no longer cover 22.5mg dosing.

Here’s the actual letter she received.


Harvard Pilgrim writes:  "HPHC has not made arbitrary decisions on the Lupron dosage for breast cancer, nor with any other policies for that matter. Rather, HPHC has implemented an IV drug management program using the best peer review medical evidence and professional societies guidelines. In the case of oncology drugs, the program has adopted recommendation from the National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 27 leading cancer centers devoted to patient care, research, and education. In Boston, MGH and DF/BW are NCCN member institutions."

Harvard Pilgrim/Caremark was very collaborative in discussing next steps, and I was eager to bring them into the conversation.  

There are 5 issues with the letter.

1.   Her oncologist was unaware that Harvard Pilgrim/Caremark had such a program.    HPHC included an article about the new program in their newsletter and sent email to those clinicians who were likely to be affected.   Although a good attempt, those communication modalities did not reach my wife’s oncologist.

2.   The rule is stated in a confusing way as "prescriptions for 3.75 mg".  How does this relate to my wife’s 22.5mg treatment?  

Harvard Pilgrim writes: "Per National Comprehensive Cancer Network guidelines, Lupron 22.5mg is indicated for prostate cancer and not breast cancer. For breast cancer, the guidelines recommend 3.75mg monthly or 11.25mg every three months (a 50% reduction in Kathy’s dose). "

Kathy would have preferred something like ‘national guidelines recommend a 50% reduction in dose to achieve the same outcome with fewer side effects’.

3.    Although Kathy’s oncologist is aware of the NCCN guideline, he believes the evidence supporting the guideline is scant (a single paper from 1990), so based on his experience with hundreds of successful cancer patients, he prefers 22.5mg.

Kathy’s oncologist writes:  "I think the Dowsett paper—and Mitch is great and a colleague—is a very small 1990 study using 2 doses of lupron in women with metastatic breast cancer.   Not very compelling evidence, especially when translated to a different clinical setting.    That being said, no one knows for sure what dose is adequate and it probably isn’t the same for all women.  In a treat for cure setting, we would rather err on the side of more drug than may be needed in that individual (as it is quite safe) rather than fail to suppress and therefore diminish effectiveness of planned treatment.   The absence of menses is not evidence of ovarian suppression since about 20% of women with no periods still have ovarian function."

Harvard Pilgrim writes:  "The NCCN guidelines support the 3.75mg IV monthly injections because the 22.5mg depots every three months’ injections do not reliably suppress estrogen in all women, which is the whole point of the treatment There are numerous examples of individual physicians who make assumptions based on their observations and individual experience. In many cases, however, those observations have not been confirmed by future clinical trials and may reflect unconscious bias on the part of the treating physician.  Kathy’s oncologist doesn’t appear to have published his observations in a peer review journalwith hundreds of patients using the off-label dose of Lupron 22.5mg every three months. In addition, if he feels strongly that the 22.5 mg is the preferred dose, he has a professional obligation to suggest modifications of the NCCN guidelines. We don’t know if he has made an attempt to modify the NCCN guidelines."

I completely understand Harvard Pilgrim’s motivation to implement a guideline, and NCCN is what is available.    The central issue with the letter is not the guidelines themselves, but how the program was implemented before patient/provider educational and workflow concerns had been addressed.

4.   The patient is being asked to manage something they lack the expertise to do - bringing together payer medical management and provider caregivers to discuss a medication dose.    

Harvard Pilgrim’s writes: "There are many avenues for appeal and the patient is not being asked to manage the process. The contracted provider, who is credentialed by HPHC and who has signed a contract with HPHC, has a responsibility to manage the process by calling the plan or the delegated entity or both, whenever he/she disagree with the initial determination. In addition, the patient and provider can submit a formal appeal requesting an external specialist’s review of the case.  In a similar different case to Kathy’s, the external expert in the same specialty  (not chosen by the plan), agreed with the NCCN guidelines and HPHC. The match specialist is a board-certified oncologist working at an academic medical center in Pennsylvania.  Finally, if the denial is upheld on first level appeal, the patient and physician can appeal to the State. The process is fair and equitable and attempts to balance self-interest and autonomy with common interest and use of evidence-based medicine with the ultimate goal of managing limited resources and continuously increasing care cost in the New England market."

I leave the readers to judge for themselves if the patient is being asked to manage a process.

Harvard Pilgrim writes: "There are many avenues of appeal if the physician does not agree and the physician has a professional responsibility  to act as the patient advocate, and to explain to the health plan medical director the rational for  supporting a treatment that is not recognized by any of the compendia (Micromedix, Facts and Comparison) and NCCN guidelines."

5.   The decision was made without consulting Kathy’s clinical record or cancer treatment protocol.   I’ve recently co-authored a book about precision medicine which highlights the need to combine evidence, patient preference, clinical history, genomics, and the experience of other patients to select the right treatments.    We all should be working toward that future.  

Harvard Pilgrim writes: "While Dr. Halamka is correct that we do not have access to clinical records, in order to ensure that we have relevant information, we ask the treating physician to provide it to us so that we can utilize it in decision-making Participating physicians are asked  to fill out a form (designed by the State) and include information relevant to the case. In addition, physicians have the opportunity to call the health plan or the delegated entity and initiate a peer to peer discussion. During the peer to peer discussion, the patient physician has the opportunity to provide the clinical rationale as of why the plan should cover a treatment that deviates from FDA, or other professional guidelines."

Again, I leave it to the readers to decide how a clinician is going to follow that workflow while having 12 minutes to see each patient, comply with Meaningful Use-imposed  EHR burdens, be empathic, make eye contact, and never commit malpractice.

Harvard Pilgrim writes:  "A physician should never abdicate his/her ethical obligation to support his/her patients in the entire process of care. Many practices delegate certain non-direct patient care functions to other members of the clinical team. However, the physician must always act as patient advocate. In this case, patient advocacy means picking up the phone and having  a discussion with a medical director at the Health Plan. . To their credit, many  physicians do call the plan and interact with the medical directors."

Sometimes in the healthcare industry we implement changes before policy, technology, and culture are ready.   For example, healthcare regulations required encryption of mobile devices  before any laptop or phone operating system supported encryption.    Meaningful Use tried to accelerate interoperability before we had an electronic provider directory, a nationwide patient matching strategy, or a framework for consistent privacy policy among states.  Care management disconnected from clinical workflow has the same problem.

Here are three alternatives which would markedly improve the patient experience

1.   The actual Harvard Pilgrim/Caremark formulary is shown below from the e-prescribing function inside my wife’s EHR.    I did an eligibility check demonstrating that both Caremark and Medimpact pharmacy benefits mangers consider 22.5 mg a preferred level 1 medication for 3 month administration without any designation that there is a care management decision support rule to consider.   Given that Kathy is female and therefore unlikely to have prostate cancer, there is no reason to offer the 22.5mg option.  Imagine if during e-prescribing, the rule was displayed/enforced so that 22.5mg wasn’t considered preferred level 1, resulting in a patient/doctor conversation before the medication is ordered.


Harvard Pilgrim writes: "The PBM or Health plan formulary is not designed as a drug management tool. The preferred product designation in the formulary is a cost management tool. The formulary must list all the available dosages so that even an off-label dosage can be dispensed, like in Kathy’s case, as an exception to the medical policy after discussion with the patient physician. Clearly, there is an opportunity to further educate providers on the difference between utilization management and formularies."

2.  As a country, we need to finalize the standards for pre-authorization with clinical attachments.    Harvard Pilgrim/Caremark could create a rule as part of the pre-authorization workflow.    Appropriate clinical documentation would be required before the pre-authorization is approved, again resulting in a patient/doctor conversation before the medication is ordered.   Alternatively, the emerging Fast Healthcare Interoperability Resources (FHIR) Clinical Decision Support Hooks specifications  will enable EHRs to query cloud hosted clinical rules and display precision medicine information to the provider at the point of care.

3.  The letter from Harvard Pilgrim/Caremark, could be revised as follows

'Harvard Pilgrim, Caremark, and your care team work together to keep you healthy.  We’re constantly reviewing evidence about the best possible treatments.     Based on recent research, it appears you are receiving too high a dose of Depot Lupron, which could cause unwanted side effects.    We will contact  your doctor and have a discussion about the protocol you are on, taking into account your individual medical history, to collaboratively decide on the best dose for you.    We just wanted you to know that in case your prescription changes, it’s all because of new knowledge and experts working together.'

I applaud the intent of care management as a way to improve quality and reduce costs.   However, just as with Meaningful Use, I think the letter is a good example of trying to do too much too soon.

I’m not asking that Harvard Pilgrim and Caremark eliminate their care management program.   I am asking that they realize the deficiencies of launching a program before the education and workflow redesign efforts were mature, putting the patient in the middle of what should be a payer-provider conversation. The tools to implement that payer-provider conversation don’t yet exist, but soon will and HPHC/Caremark could start by modifying their formularies to offer preferred choices in existing e-prescribing workflows.

As John Kotter taught us in his change management work, we need to follow a process, beginning with a sense of urgency in order to make lasting change.     We know that the US must reduce total medical expense while maintaining quality and optimizing outcomes if we are to have a sustainable economic future.   Care management based on evidence is the right thing to do.    Now we need to work together so that payer systems, decision support rules, and EHRs have a closed loop workflow for all involved.     I’m happy to serve on the guiding coalition, along with my colleagues at HPHC, to make this happen.

Thursday, August 17, 2017

Building Unity Farm Sanctuary - August 2017

I’ve put down the pitchfork and shovel, returning to the keyboard to update everyone about our Sanctuary progress.    Here’s what’s happened over the past few weeks.

As Kathy wrote on Facebook on July 25, Pippin, our 30 year old Welsh Pony passed away from cancer.   His last few months included daily play with three other ponies, walks in the woods, and generous servings of grain/treats.    He was the centerpiece of our horse work at the sanctuary and we miss him every day.   He’s buried on a hill covered with oaks overlooking the barnyard marked by a large flat stone.

The sanctuary volunteer program now includes over 20 people who feed, bathe, exercise, socialize and medicate all the inhabitants of the sanctuary.    We also have volunteers helping out with the agricultural duties - harvesting, planting, and weeding.    This amazing outpouring of support from the community enables Kathy and I to keep everything (well almost everything) on track.

The new paddocks are almost done and we’ve officially begun placing the half mile of fencing around the new run ins.     After Labor Day, we’ll have enough capacity to take on a small herd of mini-horses, pictured below.    Between the sanctuary and farm we’ll have 20 stalls and 10 paddocks.   With help from a local excavator, we’ve dug the trenches and laid the pipe/wire  so that each stall has heated buckets, lighting, and easy access to water.


Lunchbox Benson, a vietnamese pot belly pig, nipped one of our volunteers on her ankle.   We flushed the area to ensure it was clean enough to bandage and sent her for medical followup.    Lunchbox has never shown any unsociable behavior, so we’re concerned that one of his tusks may be growing into his palate, making him defensive.   We’re searching for a vet with experience in pig dentistry - not an easy task.

Over the next month, the pace of farm activities will continue at a fever pitch as we harvest the remaining summer fruits/vegetables, garlic, plant the fall/winter crops, and begin preparation for winter.    All our construction and improvement projects will wrap up in September.   As Kathy and I joke, when we’re 64 in 9 years, the daily heavy lifting  will need to slow down.   (And Kathy assures me that she’ll still need me and will still feed me)


We set the foundation for the Unity Farm sanctuary flagpole this morning - a 25 foot fiberglass single piece that is weather resistant and will not attract lightening.    Kathy has designed the sanctuary flag that we’ll fly.


As a place of peace and protection, the Sanctuary continues to be a haven for local wildlife.   Yesterday, a dozen wild turkeys visited Star the donkey.    Thus far, all the local animals - coyotes, foxes, fisher cats, raccoons, possums, skunks, hawks, turkeys and deer pass the through the sanctuary every day without a problem.    There must be something about the environment which encourages good behavior.


The carriage house refinishing project is now finished, complete with a coat of USDA approved epoxy on the floors.   We’ve moved all the honey processing equipment from the cider house to the carriage house so we can more easily keep the bees out and ensure complete cleanliness of the honey products (cider processing includes a lot of flying apple chunks).    Kathy’s 40 hives have been productive this year and we’ll process nearly 1000 pounds of honey.

We’ve just completed our 2017 organic certification, following all the rules and documenting our compliance with organic best practices.   The onsite unannounced inspection will happen soon.

The rainy summer has produced a bountiful Shiitake mushroom crop and we picked 40 pounds last week.    We’ve delivered fresh organic mushrooms, cucumbers, basil, eggs, and lettuce to Tilly and Salvy’s farmstand in Natick.

Hopefully this gives you a sense of everything that has consumed us nights and weekends, reducing my writing time.     I promise to do better in the Fall!

Sunday, August 6, 2017

Unity Farm and Sanctuary Guest Post

Over the past few weeks I've been writing a few journal articles and finishing a book, so my blog posts have waned.    They will start again soon.   In the meantime, my mother is visiting and here is her guest post.


Dagmar Halamka's farm notes from August 4,2017 and August 5, 2017.

The beauty here is infinite - wildflowers everywhere, bee colonies in colorful hives, gushing fountains in ponds with swimming ducks and geese and vast amounts of greenery because of the frequent rain.  60 acres of enchanted forest  that even "House and Garden" magazine could not duplicate surround the farm.  Roosters begin crowing about 4:30am. A very slow moving freight train provides a marvelous whistle several times a day as it moves through the countryside.

Today was Blueberry picking day at Unity Farm.  It’s hard work!  An hour and a half of picking rendered one bucket (I ate a "few"). I am renegotiating my contract!

Palmer, the turkey, followed us around all day - wherever we went. He extends his plumage often so we can admire how grand he is. When I returned with the blueberries, ALL the geese greeted me with extensive honks (males) and hinks (females). I think they believed I had food for them.

Then planting time arrived - I planted 45 lettuce seeds. Really easy since John had already provided the soil blocks.

We streamed "Lion" yesterday evening. I highly recommend it. A beautiful story with an
endearing plot theme.

We visited the new "age restricted" (over 55) condominiums at Abbey Road - just 500 yards from Unity Farm on the trails through the sanctuary. I was immediately surprised by the Revolutionary W War era cemetery in the front of the development.

Tuesday, the local Garden club will come to Unity Farm for a potluck. Kathy admitted they will
market living in Sherborn to me.

Who knew that a machine existed to wash eggs - with an alkaline egg wash solution? The next step is to brush each one with a toothbrush and finally float them in a sink of water to determine if they sink or not (don’t eat the ones that float). We washed 10 dozen eggs.

I decided to walk to the post office (and to treat myself to ice cream at the C and L Frosty).   I was sauntering back when a torrential rainstorm appeared, seemingly out of nowhere. Kathy drove down in the car and truly rescued me.

Dinner with John’s daughter was at a Japanese restaurant in Wellesley. They lived
there before moving to Sherborn. So it has sentimental memories for her. She loves her job at "Game Stop"- especially interacting with all the customers.

More tomorrow.

Thursday, July 6, 2017

Reflections on the US HIT Policy Trajectory

I’m in China this week, meeting with government, academia, and industry leaders in Guangzhou, Shenzhen,  Beijing, Shanghai,  and Suzhou.    The twelve hour time difference means that I can work a day in China, followed by a day in Boston.    For the next 7 days, I’ll truly be living on both sides of the planet.

I recently delivered this policy update about the key developments in healthcare IT policy and sentiment over the past 90 days.

I’ve not written a specific summary of the recently released Quality Patient Program proposed rule which provides the detailed regulatory guidance for implementation of MACRA/MIPS, but here’s the excellent 26 page synopsis created by CMS which provides an overview of the 1058 page rule.

In general, it has many positive provisions.

The industry is welcoming the delays and accommodations it includes, especially the use of 2014 certified records for the 2018 year and the small practice exemptions which recognize the technologies/people/processed needed to succeed under MACRA/MIPS could overwhelm independent clinicians.

The Senate replacement for the Affordable Care Act continues to be debated and there is concern that loss of medicaid dollars may eliminate funding streams that supported healthcare IT.   It’s too early to tell where the ACA repeal/replace activity will converge.

What can we say about the IT policy direction of the US right now?

1. There seems to be great consensus that all stakeholders need to focus on enhancing interoperability technology and policy in support of care coordination, population health, precision medicine, patient/family engagement, and research.  

2.  There is also a consensus that usability of the IT tools in the marketplace needs to be enhanced.   Although the major EHR vendors are working on usability improvements, I believe the greatest agility will come from startup community via apps that get/put data with EHRs using APIs based on evolving FHIR standards.    Here’s my sense of each vendor’s approach

Epic - will support open source FHIR APIs at no cost for the use cases prioritized by the Argonaut working group and HL7.  Will also support proprietary Epic APIs for Epic licensees.

Cerner - similar to Epic with additional SMART on FHIR support

Meditech - will support open source FHIR APIs and give encourage developers to work with customers to leverage the SQL-based Meditech data repository at each customer site.

Athena - will support open source FHIR APIs at no cost but give much more sophisticated workflow integration through the more disruption please program, which involves revenue sharing with developers.

eCW - the department of justice settle should lead to additional eCW support for standards based data exchange.  

3.  Many organizations in industry, government, and academic are thinking about patient identity strategies.  It’s too early to know what solutions will predominate but leading contenders are biometrics (fingerprint, image recognition, palm vein geometry etc.), a voluntary national identifier issued by some authority (public or private sector), or some creative software solution such as OAuth/OpenID/Blockchain etc.  In July, I will co-chair a national consensus conference on patient identifiers hosted by the Pew Charitable Trust.   I’m hoping we achieve consensus on a framework that accelerates the availability of such an identifier for multiple purposes.

4.  Several groups are thinking about how best to converge our heterogenous state privacy policies, specifically focusing on  the role of the patient as data steward.   We can radically simplify privacy protection if the patient is the agent by which information is shared.

5.  Finally, there seems to be an overwhelming sentiment that the concept of certification  and prescriptive IT policy should be replaced by an outcomes focus.    Rather than counting the number of Direct messages sent, giving organizations the flexibility to each data using the the most locally appropriate technology but then holding them accountable for a result of that data exchange i.e. reduced readmissions, reduced redundant testing, reduced errors seems to be well aligned with a move to value-based purchasing.

In theory the members of the new Healthcare Information Technology Advisory Standards Committee (which replaces the former Policy and Standards Committees)  will be named in July.    I look forward to hearing about the initial challenges the group will tackle.   I’m hopeful they will choose some of the issues mentioned above.

In several recent lectures, I’ve reinforced my optimism for the future of the healthcare IT ecosystem.   I believe the next few years will be filled with market driven innovation, encouraged by new consumer demand for healthcare process automation and supplemented by low cost, cloud based utility devices such as the machine learning and image recognition APIs offered by Google and Amazon.    It will be a great time for entrepreneurs, providers, and patients, all of whom are fatigued after years of Meaningful Use, ICD10, and accelerating  numbers of quality measures.   As a CIO, I’m looking forward to doing what my customers want me to do instead of being told what I must do.

Sunday, July 2, 2017

Building Unity Farm Sanctuary - First Week of July 2017

Admittedly, the pace of my writing has slowed this Summer since each day is filled with a combination of IT work, mentoring, and keeping 60 acres of farm/sanctuary running smoothly.    How’s it all going?  Our trajectory is good.

So much of what we’re doing  at the farm/sanctuary is improvisation that we have no choice but to create a vision and accept ambiguity on the daily journey.

We received a request to adopt a house pig - Rue, who’s 80 pounds at 4 years old and extremely well behaved.  We’ve been socializing her with the other pigs and thus far, all is proceeding as expected - they challenge each other across a fence and eventually accept their place in the social hierarchy.    Now that we have 5 pigs, the question we asked is what is their ideal living arrangement - how can we create a pig “condo complex” that works in summer and winter for everyone.  


Sometimes a sense of urgency is needed to motivate change.    We have 8 baby turkeys and they needed a safe outdoor home.    Although we built an aviary last year, Penny, the Yorkshire pig, was living in the aviary at night because she was not ready to spend the night with Tofu and Lunchbox, the pot belly pigs.    Although we knew it would cause one night of anxiety, we put all of them together in a paddock and gave Penny a separate crate so that she could have a private space.    After a few nights, she began sleeping with the other pigs and now all of them cluster in a single pig pile, completely happy together.   The empty aviary became the home for the baby turkeys.

We put Rue and Hazel together in a paddock separated by fence.    At this point they are rubbing noses and not fighting.  After another month, we’ll take down the fence.  

The new arrangement - 3 pigs living in one paddock and 2 pigs living in another - completely supports our daily routines and workflow.   The farm is a continuous experiment and this time it all worked.

Similarly, it’s clear that our 5 horses will have a natural grouping - the dominant Arabian (Amber) and the assertive Welsh Pony (Sweetie) will get along perfectly.    The older Welsh Pony (Pippin), the shy Welsh Pony (Grace), and the good natured Welsh Pony (Millie) will be a perfect herd.  

Our new paddocks and run ins are progressing well.   The horse groups above will occupy two paddocks, we’ll leave one paddock open for exercising/running, and leave a paddock for whatever flexibility we need to continue our sanctuary mission.

The last experimental animal grouping that is working very well is the combination of goats and a donkey.    Star the donkey is doing well on her diet/exercise program and after a year, she’ll have a healthy weight.   The goats can eat her food but she cannot eat the goats food.     They keep each other company and are very happy.

If you asked me a few years ago if we would be the stewards of horses, donkeys, pigs, llamas, alpacas, geese, ducks, chickens, guinea fowl turkeys, Great Pyrenees and bees, I would have questioned your sanity.     Now every creature is part of the daily fabric of our lives and we treasure all of them.

The Sanctuary volunteer program is in full gear with multiple people donating time to the sanctuary every day.    They are grooming horses, walking the donkey, feeding poultry, cleaning paddocks, and socializing with the pigs.   The sanctuary has become such a community destination that there is not a moment of private time left on the property - and we’re ok with that.    My advice to our family - always stay dressed!

A mother rabbit had a litter of 4 babies in the middle of the orchard.   I did not realize that rabbits create hidden burrows in grasslands so that their young are just under the surface.    While walking through the orchard I heard a squeak and picked up the baby pictured below - I returned her immediately to her mother and the family in the rabbit den.


It’s early Summer harvest time and we’ve picked a few hundred heads of lettuce, 4 beds of basil, strawberries, cucumbers, and peas.   Garlic, tomatoes, and peppers are next in line.

Will I ever have time to continue the volume of writing I once did?  As building the sanctuary and nursing the animals back to health is replaced with maintaining the sanctuary and helping the animals thrive, there is a certain routine that will return to each day.    Waking up a dawn, feeding/watering, walking, cleaning, and medications takes about 2 hours.   Then comes, the work day.  Evening chores to prepare everyone for a safe and quiet night takes about 2 hours.    It’s common for Kathy and I to sit down for the first time each day at 9pm.   As I reflect on this stage of life - 33 years of marriage, 20 years as a CIO, and a married daughter living in her own household - having the joyful chaos of the farm and sanctuary 7x24x365 is exactly right.

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.