Thursday, July 23, 2015

Unity Farm Journal - Third Week of July 2015

In yesterday’s blog post, I wrote about mobile devices and my own blood pressure variability.  

The one time that my blood pressure is normal is during a day of farm work.   After hauling wood, planting/harvesting, caring for animals, maintaining trails, and repairing infrastructure, I’ll walk down our farm road through the orchard on the way back to the house.   All the tension of the week fades away with walk along the road.

Last week we moved 10,000 pounds of manure from the barnyard compost area to wind rows near the orchard.   We use “llama beans” to amend the soil in our hoop house and supplement our trees/squash beds.    A heavy rain made the manure very heavy and on the way to the wind rows, a buried underground stump collapsed, causing the Terex front loader to tip over with a 1000 pound load.    Luckily I was standing nearby and the opened the emergency exit for the driver who exited unharmed.   We used a truck and heavy duty nylon webbing to pull the Terex back into the upright position.   No harm done!

With the manure cleared, we’re redesigning the barnyard so that we can install a 17’x24’ hoop house for equipment storage - moving the Terex out of the barn and the mowers out of our pasture lean-to’s.    We’re also creating an area that might be used for pigs in the future.  We’ve scaling back our wood storage to just 4 cords (from 8 cords).   We’re re-grading/leveling the barnyard and applying gravel to the working surfaces to minimize the low spots that become mud wallows.   With every passing season we’re learning more about how to run a farm and optimize the physical arrangement/equipment to minimize maintenance tasks.

We did our annual vet visit for a full physical exam of all the animals this week.   The 14 camelids (alpaca/llama) are entirely healthy.   We gave the rabies and clostridial vaccines, checked their nutritional status, and carefully examined eyes/ears/teeth.    The only issues were that the llama is slightly overweight (but no change from last year) and one of our older alpaca has irritated eyes that we’re treating with ophthalmic ointment.   Our young alpaca continue to grow like weeds.   Danny (4 weeks old) is now 35 pounds and Sunny (1 year old) is 85 pounds.

The geese continue to follow us around the farm.  It’s as if we have 5 dogs - two Great Pyrenees plus 2 buff geese and 1 tuft goose.

The young chickens are learning the ropes of farm life, roosting in the coop night, staying safe from hawks during the day, and avoiding conflict with the other birds.

At midsummer, the hoop house is filled with peppers, tomatoes, cucumbers, eggplant, and beans.  I fill a basket with fresh food every night.   Kathy is busy pickling and preserving the foods we’re not eating now.

The weekend ahead includes harvesting our garlic, potatoes and squash.   I’ll plant a few beds of lettuce and chard for early Fall picking.     We’ll spin frames of honey and bottle in anticipation of mead making and honey lager brewing this Fall.

I’m working remotely on Mondays and Fridays in August.   Although it seems early, the planning for harvest and the winter ahead is already in progress.

Wednesday, July 22, 2015

Patient Generated Healthcare Data

I’ve often written about the IT strategies of Accountable Care Organizations and the need for a Care Management Medical Record which incorporates EHR data, patient generated data, customer relationship management features, protocols/guidelines and a workflow engine.

Although I have yet to see mature products in the marketplace, components are evolving that will fundamentally change the way we deliver care.

People know that I have been very transparent about my own medical history, as described in this Politico editorial.

Here’s how I’m using Patient Generated Healthcare Data in my own care management activities.

For the past 15 years, I’ve had a supraventricular tachycardia (SVT) - an AV nodal reentry issue.    My resting heart rate is 45-50 beats per minute.   On hot days, after I’ve eaten, my heart rate leaps to 170 beats per minute if I exercise vigorously then suddenly stop.     I perform a Valsalva Maneuver  and within a few minutes, my heart rate returns to normal.

I’ve never had any lasting consequences from this SVT.    I could take beta blockers, have an ablation of the ectopic pacemaker in my heart, or just accept that a few times per year I’ll have an arrhythmia.    I’ve chosen the later.

We’ve attempted to capture an ECG of my arrhythmia, but have never been successful.  We’ve tried a stress test, a holter monitor, and other wearable approaches.   It occurs too infrequently to capture.

We now have a solution.   I have attached an AliveCor ECG monitor to my iPhone 6.   The next time I have symptoms, I’ll just hold my phone and capture a perfect Lead I ECG.    From my phone, I can send it after capture to my PCP and the BIDMC electrophysiology expert for review.    It will be reassuring to know that I do not have episodic atrial fibrillation or an unstable ventricular tachycardia.

The cost of this technology is $70 dollars.

Although my body mass index has been constant at 22 for the past 15 years and my caffeine free, low sodium, vegan diet has kept me healthy, my genome is finally catching up to me and I’m starting to experience the essential hypertension (systolic of 140-150) that has been present in generations of both sides of my family.    Diet, exercise, blood pressure monitoring, vitamin D (may be helpful), and salt restriction are reasonable first approaches.   If they fail, then thiazide diuretics, calcium channel blockers or ace inhibitors are the next step, presuming there is no underlying root cause to treat.

As part of my initial assessment, I’m using a Withings Wireless blood pressure monitor with my iPhone 6.

I’m taking readings when I first wake up, before/after the Massachusetts Turnpike commute, at the end of the business day, and before bed.

Thus far, I’m seeing normal blood pressures on weekends after a day of farm work.  I’m seeing 140-150’s after the commute.   In case you’re not familiar with driving in Boston, it looks like this 

After a 12 hour day of meetings, I’ve seen a few spikes to 160, then a return to 130’s by bed time.

All of my measurements are uploaded automatically to the BIDMC electronic health record from my phone within 1 second.

The cost of this level of monitoring is $120.00

I also use a Withings Pulse to monitor my steps/elevation/distance/calories burned/pulse/pulse ox and a Withings Smart Body Analyzer to track my weight/body mass index.

All of this data is displayed with a variance analysis on my phone.

I’m not endorsing these products and have no financial relationship with either AliveCor or Withings.   I’m simply describing my experience that an iPhone 6 can become a middleware hub for healthcare information, enabling me to be the steward of my own data and share it with a healthcare system/provider at minimal cost.

The devices are easy to use and there is end to end data integrity from point of origin (the measurement) to point of use (the doctor).  

It’s clear to me that patient wellness (rather than treating sickness) will require more objective and subjective (pain score, mobility, mood) data than we gather today.   EHRs are not yet optimized for incorporating these novel data sources, but the Care Management Medical Record used for team-based coordination of life time care, must leverage the power of new healthcare enabled mobile devices.

Thursday, July 16, 2015

Unity Farm Journal - Second Week of July 2015

Living on the farm means that every day is an adventure.   As Forrest Gump said, “you never know what you’re going to get”.

Last Thursday evening, at midnight, the Great Pyrenees began to bark with a cadence and volume that indicated a serious problem.   The llama began to trumpet.   The guinea fowl began to "buckwheat" inside their coop.    The ducks and geese quacked and honked.

I grabbed a flashlight and ran out to the barnyard.   A pack of 12 coyotes was circling the alpaca paddock, howling at the top of their lungs.  There were old, adolescent and young coyotes all making menacing movements toward the alpaca.

The coyotes and I have a tenuous relationship.    Like other predators, I know they are the top of food chain and play a valuable role in the ecosystem.   I’m a vegan and do not want to kill/injure any living thing.

When a single coyote appears in the barnyard I chase it away (or the guineas gang up on it).    With a pack of 12, I was a little less sure of myself.    I immediately began yelling at the top of my lungs I broke a few thick branches across a tree trunk, making a very loud noise.     I do not own a firearm (although Kathy and I are licensed to do so), and recognized my options to defend the animals were limited.

I threw rocks at the trees/bushes in their general direction, further creating noise.  They backed off.

Did I know what I was doing?  No?  Was it the right thing?  Per WikiHow, I did everything right when encountering a coyote pack.

The coyotes have not returned and all the animals are safe.

Keeping predators away was important this week since we released our eight week old chickens into the barn yard to free range.   We released

3 Buff orpingtons
6 Barred rocks
2 Andalusian blues
2 Ameraucana
2 Cuckoo marans
2 Golden laced wyandottes

that we had been raising in our mini-coops from 1 day old chicks.

They are running all over the property (including a rest on the air conditioners) and each night have come safely home to the coop.

With the mini-coops empty, we moved the last of our baby chicks (Ameraucanas) to the mini-coops and we moved 7 pheasants to the chicken pen, where they will mature until they are 16 weeks old and we can release them to the forest.

The geese continue to patrol the property and act like watchdogs.  This week they learned to swim but they still aren’t sure what to do with running water (streams are scary)

The bees continue to make honey, capturing the last of the summer nectar from the wildflowers around the farm, including this grove of mint.

We’ve completed the picking of our strawberries raspberries, gooseberries, and early blueberries for the season.   The mid-blueberries should be picking next week and the late blueberries in August.

Our coursework at Umass is going well.  I’m learning a great deal about the role of temperature, humidity, ethylene, O2/CO2, and physical handling of vegetables post harvard.

As Kathy and I think about our strategic plan for the year, we’ve both agreed that we must be careful not to produce too much of any one commodity and find that farm life has become a burden instead of a joy.   We’re working on refining our daily routines, automating processes, reorganizing workflows, and thinking about the right tools that will simplify our tasks.    At the moment, I’m adding a 16 cubic foot trailer to the barnyard so that we can more easily haul manure to windrows in the orchard instead of composting thousands of pounds of manure for months then moving it in mass.   I’m considering another hoop house just to keep the farm equipment organized and out of the elements.  I’m refining the layout of the barnyard.  

Just as a hospital would re-engineer its business using toyota production techniques (LEAN, six sigma etc), we’re doing the same.   Who would have thought that engineering ideas would be so useful in an agricultural setting!

Wednesday, July 15, 2015

Trajectory not Position

In my various state, federal, and international roles I interact with a large number of policy makers from the executive and legislative branches of government.  I testify to them, write policy papers, and call their support staff frequently.

At the moment in our society,  there tends to be a general proclivity to be a criticizer rather than a doer, to tear down rather than build up, and to have hearings instead of taking individual action.

Everyone talks about what has not been done instead of examining the progress made.

A great deal of leadership time is spent defending the actions of the past, making promises for the future and filling the present with powerpoint instead of programming.

How do we break this cycle of negativity?

My view is that we must believe in incremental progress, communicate broadly, and focus on our trajectory not our position.

What do I mean?

Ten years ago when I chaired the Health Information Technology Standards Panel (HITSP), the debate focused on such topics as

Is your XML better than my XML? (CCD versus CCR)
Is your HL7 2.x implementation guide better than mine?
Should LOINC coding of labs be required?
Can clinicians code problem lists using SNOMED-CT?
Are electronic public health submissions even possible?

In 2015, none of these items are debated.  The dialog has shifted beyond controlled vocabularies to such topics as building trust fabrics across organizations, refining transition of care standards and embracing new architectures based on FHIR/OAuth/REST.

John Kotter taught us that all change requires a sense of urgency.   I agree that there is an urgency to improve healthcare IT usability, workflow, and functionality.    

However, there is no need to panic.     We are in the biplane era of healthcare IT.    Flying cars are better than biplanes but that does not imply we can widely deploy flying cars without inventing jet aircraft first.    There are logical steps from our current state to our future state.

When I testify, I listen intently to questions and commentary.    Often there is limited domain understanding of the nature of healthcare data, existing regulatory requirements, and clinical workflow.    Rarely is technology the rate limiting step to innovation - the challenges are policy, psychology, and culture.

At age 53,  my personal medical data is electronic.   That was not true when I was 43.

At age 22, my daughter has never encountered a paper based record as an adult.   She has always had access to 100% of her healthcare data on her iPhone.  That was certainly not the case for me.

Since 1996, our ability to respect patient privacy preferences has improved immensely.   See this twenty year review of HIPAA that illustrates how far we’ve come.

Some people call me overly optimistic.   I tell people I am even tempered and predictable.   I will neither over promise future progress nor use hyperbole to over simplify the complexity of the process issues involved in IT transformation.

I  look at the experience of three generations of my family.  The trajectory of IT over the past 10 years has been overwhelmingly positive.    The next 10 years will continue to improve data liquidity, patient access, and usability.

Let’s all be doers.    Our position will be imperfect because there will always be room for improvement.   However, looking back after years of effort I can say that our trajectory vanquished many IT dragons along the way.

Thursday, July 9, 2015

Unity Farm Journal - First Week of July 2015

It’s a week for strategic planning.   Just as I wrote a basic draft framework for  FY16 BIDMC information systems, I’ve written a draft plan for the next year at Unity Farm.

Here’s our best thinking as of July 2015:

Unity Farm was founded on a few basic principles

1.  A complete environment that challenges us mentally and physically
2.  A nurturing place for animals and plants
3.  A place that enables us to pursue a life focused on sustainability
4.  A place to reduce and optimize belongings
5.  A place for generations to gather

It is meant to be a labor of love, not a profit center or large supplier of any one commodity.   It will be diverse, experimental, and manageable without requiring a permanent staff.

The Living Things

Alpaca/Llama - we have the barn facilities for housing no more than 14 camelids i.e. 5 male alpaca, 8 female alpaca, and 1 llama.   Our breeding program will be limited to keeping the herd vital.  We will not breed camelids for sale.

Dogs - the Great Pyrenees dogs are our companions and have successfully kept predator losses to a minimum.    Recognizing that their lifespan may not exceed 10 years, we’ll have to plan for replacement/possible overlap of young/old but will only keep two dogs at steady state.   We will not breed dogs for sale.

Cats - the cats keep our indoor rodent population under control and provide a vibrant presence inside the house.

Ducks - we have the facilities for housing no more than 12 water birds.   They provide eggs, fertilizer, and insect/slug control.   We will not breed ducks for sale.

Geese - we have the facilities for housing no more than 12 water birds.   They eat weeds and guard the barnyard against predators.    We will not breed geese for sale.

Chickens - we have the facilities for housing no more than 100 land birds.   They provide eggs, fertilizer, and insect control.   We will not breed chickens for sale

Guinea Fowl -  we have the facilities for housing no more than 100 land birds.  They provide tick control and guard the barnyard against predators.    We will only sell guinea fowl when the population exceeds 60 birds.

Pheasants - we have a property size that can accommodate 6 pheasants.   They will be released at maturity and propagate in the forest as nature allows.

Bees - we have the nectar sources that can accommodate 12 hives.   We will maintain 22 hives by keeping bees at multiple local properties.

Pigs -  We have space for 2 pigs.  Pigs can efficiently process our fruit waste/pomace, vegetable waste, and edibles that would otherwise be composted.   We will not breed pigs for sale.   They would be companion animals.

Others - we will not add sheep, goats, horses, donkeys, or cows to Unity Farm.

The Products

Vegetables - We’ll grow four seasons of vegetables in the hoop house for Unity farm friends/family and creatures.  We will not sell fresh vegetables.

Orchard - We’ll grow apples, stone fruits and berries for Unity farm friends/family.  We will sell not run a U-pick.

Mushrooms - We’ll grow Shitake, Agaricus, Winecap, Nameko, Oyster, Lion’s Mane, and Ganoderma for Unity farm friends/family.  We will sell Shitake.

Cider and beer - We’ll make hard cider and beer for Unity farm friends/family.  We will sell cider.

Honey - We’ll make honey and wax products for Unity farm friends/family.  We will sell honey and wax.

Mead - We’ll make mead for Unity farm friends/family.  We will sell mead.

Eggs - We’ll have eggs for Unity farm friends/family and sell eggs.

Fiber - We’ll harvest fiber yearly and sell yarn.

Permaculture - We’ll experiment with paw-paw, ginseng, and other produce to determine what works in our environment.

Goals for next year

1.  Coursework in the UMass Sustainable Food and Farming Certificate Program
2.  Raise 21 young chickens, 3 geese and 6 pheasants
3.  Try permaculture experiments  (paw paw, ginseng, rice, sun choke)
4.  Refine cider, mead and beer recipes
5.  Raise our young alpaca
6.  Build up our 22 hives for winter
7.  Evaluate the best use of our remaining barnyard space - build a pig enclosure or an equipment barn
8.  Grow vegetables, fruits, and mushrooms
9.  Process our alpaca fiber
10.  Maintain woodland and trails