Thursday, December 8, 2016

Unity Farm Journal - Second Week of December 2016

Every night, Kathy and I sit by the fire and debrief on the events of the day.    What rescue animals did we take on?  What new projects need to be started? Is there new infrastructure required?  Were their notable events at Unity Farm and Unity Farm Sanctuary? On our to do list, have we addressed the needs of all living things?

This week we agreed to take on 3 goats - Charlie (black alpine), Billy (white alpine) and Napoli (black pygmy cross), three wethered (gelded) males.  We do not have a lot of history on them, (not even their ages) since they came from an unfortunate situation where they weren't receiving proper care.   Charlie and Billy are very affectionate.   Napoli is a bit shy but with time will trust us.    They’ll arrive at the Sanctuary next week.

There has been a heart breaking abuse situation with 1400 animals at a farm in Westport, MA  and we stand ready to take on some of the rehabilitation tasks, even if it is just fostering.   We never intended to host cows at the Unity Farm Sanctuary but given the rescue need, we’re evaluating the requirements of bovine habitats.

We had our first snow of season this week and the pigs are not happy with cold feet.    Hazel and Tofu, who lived alone before coming to Unity Farm, have developed a mutual tolerance for each other and sleep together for warmth.    Lunchbox, our newest pig, is friendly and outgoing but Hazel still has not accepted him into the herd.   We’ve put a panel heater in his temporary housing (a large doghouse) and he’s staying comfortable through the snow and ice.   The family of the young Yorkshire pig we're assisting will visit next weekend and we'll determine together if our farm can help.

I’m heading to Israel this afternoon as part of the governor’s delegation which means Kathy will manage the farm for the next few days.   As I was leaving, we got a call about additional goats to rescue (before they are eaten).    Kathy may take the Ford Transit van to Southern Massachusetts to pick them up.   I’m sure the drive home will be interesting.  Let’s hope her passengers cooperate.  

This week we traded in our 2012 Prius C for a 2016 Ford 150 Truck.  I know that sounds like a very strange swap, but our needs have changed.   Pulling a trailer full of horses, cows, llamas, goats, or donkeys doesn’t work so well with a Prius.   The Farm and Sanctuary will have the Transit van for small animals and food pickup/delivery, a truck and trailer for hauling large animals, and my wife’s Prius V for transporting people.    It’s a good balance.

This weekend we’ll have temperatures in the 20’s and all our surface water will freeze, so we’ve put out all our bucket heaters and electric waterer bases.   We now begin 8 weeks of bitter cold that will challenge every creature on the farm.   We’ll keep them well fed/hydrated, put out extra bedding material and close each building in the evening to minimize wind/moisture.    We’ll do our chores in parkas and thick gloves.   As a farmer, you cannot fear the cold and dark mornings, you must accept the responsibility of serving the living things that depend on you.   That’s what gets us out of bed every morning!

Wednesday, December 7, 2016

21st Century Cures and the Road Ahead

I’ve been writing fewer posts recently because the trajectory forward for healthcare and healthcare IT seems to be evolving very rapidly.   In just the past week, we’ve had

*The American Hospital Association letter suggesting that 21,000 pages of regulations be rolled back including Meaningful Use Stage Three concepts and quality measurement in many care settings.

*The passage of the 21st Century Cures bill and its many IT related mandates

*The nomination of Tom Price for HHS Secretary  and Seema Verma for CMS administrator

As I’ve written about previously, I believe that value-based purchasing and the move to reimbursement based on quality measurement will still continue.    QPP , IPPS  and OPPS  will rollout as scheduled.

What can we expected from 21st Century Cures?   Here’s an IT centric evaluation:

*The HIT Policy Committee and HIT Standards Committee will be consolidated into the HIT Advisory Committee.  Thus, we’ve gone from HITSP in the Bush administration to HITSC in the Obama Administration to HITAC in the Trump administration.

*Sec. 4001. Assisting Doctors and Hospital in Improving Quality of Care for Patients -  ONC shall encourage, keep or recognize voluntary certification of health information technology for use in medical specialties and sites of service for which no such technology is available or where more advancement is needed. Requires the Secretary of HHS to submit a report to the HIT Advisory Committee on the attestation statistics for the Medicare and Medicaid EHR Meaningful Use Incentive programs to assist in standards adoption.

*Sec. 4002. Transparent Reporting on Usability, Security, and Functionality.  One year after the enactment of Cures, the Secretary through rule making, shall require that a health information technology developer or entity does not take any action that constitutes information blocking, does not prohibit or restrict communications, has published application programming interfaces (API), has successfully tested the real world use of the technology for interoperability, has provided the Secretary with certain performance attestations, and has submitted reporting criteria.  The Secretary may encourage compliance with the conditions of certification and take action to discourage noncompliance, as appropriate.  Eligible professionals maybe exempt from the application of the payment adjustment if the Secretary determines that compliance with meaningful EHR use is not possible because the certified EHR technology used by a professional has been decertified. This may also applicable to MIPS eligible professionals.

*Sec. 3009A. Electronic Health Record Reporting Program . No later than 1 year after the enactment of Cures, the Secretary must convene relevant stakeholders for the purpose of developing a wide range of reporting criteria including interoperability, security, and certification testing.  Relevant stakeholders include health care providers, including primary care and specialty care health professionals; hospitals and hospital systems; health information technology developers; patients, consumers, and their advocates; data sharing networks, such as health information exchanges; authorized certification bodies and testing laboratories; security experts; relevant manufacturers of medical devices; experts in health information technology market economics; public and private entities engaged in the evaluation of HIT performance; quality organizations; experts in human factors engineering and the measurement of user-centered design; and other entities the Secretary determines appropriate. The Secretary shall award grants, contracts or agreements to independent entities to collect the information required to be reported. Includes the authorization of $15 million to support the ONC’s certification process.

*Sec. 4003. Interoperability. Includes new language instructing the ONC, NIST, and other relevant agencies within the Department of HHS to convene “public-private and public-public partnerships to build consensus and develop or support a trusted exchange framework, including a common agreement among health information networks nationally.” Includes rules of construction language and states that the trusted exchange framework and common agreement shall “take into account existing trusted exchange frameworks and agreements used by health information networks to avoid the disruption of existing exchanges between participants of health information networks.” Defines interoperability as HIT that:

“Enables the secure exchange of electronic health information with, and use of electronic health information from, other health information technology without special effort on the part of the user”

“Allows for complete access, exchange, and use of all electronically accessible health information for authorized use under applicable State or Federal law”

“Does not constitute information blocking”

ONC shall publish the trusted exchange framework and common agreement developed one year after the convening of stakeholders. ONC must publish a list of health information networks that have adopted the common agreement and are capable of trusted exchange no later than 2 years after the convening of stakeholders and annually thereafter. Federal agencies contracting or entering into agreements with health information exchange networks may require that each network adopts the trusted exchange framework and common agreement

* Sec. 3003. Setting Priorities for Standards Adoption. The HIT Advisory Committee will identify priority uses for HIT focusing on priorities arising from the implementation of the incentive programs for the meaningful use of certified EHR technology, MIPS, Alternative Payment Models, the Hospital Value-Based Purchasing Program, and any other payment programs. Committee will also identify priorities related to a number of different issues including public health, privacy and security of electronic health information, and individual access. Committee will also identify existing standards and implementation specifications that support the use and exchange of electronic health information.

*Sec. 3022. Information Blocking
Defines information blocking  as a practice that “is likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information; and if conducted by a health information technology developer, exchange, or network, such developer, exchange, or network knows, or should know, that such practice is likely to interfere with, prevent, or materially discourage the access, exchange, or use of electronic health information; or if conducted by a health care provider, such provider knows that such practice is unreasonable and is likely to interfere with, prevent, or materially discourage the access, exchange, or use of electronic health information.”   The Secretary, through rule making, may also identify reasonable and necessary activities that do not constitute information blocking.  The HHS Office of the Inspector General may investigate claims of information blocking or false attestations and may issue penalties up to $1 million per violation.

*Sec. 4005. Leveraging Electronic Health Records to Improve Patient Care  Requires that electronic health records be able to transmit data to and from registries, such as clinician-led clinical data registries. Adds that health information technology developers shall be treated as patient safety organizations for the purposes of reporting and conducting patient safety activities concerning improving clinical care.

*Sec. 4006. Empowering Patients and Improving Patient Access to Their Electronic Health Information. The ONC shall promote policies that ensure that a patient’s electronic health information is accessible to the patient and/or designees to facilitate communication with other health care providers and other individuals, including researchers, consistent with such patient’s consent.  Lays out an educational effort for health care providers and patients on allowable sharing of patient health information.

* Sec. 4007. GAO Study on Patient Matching  Requires the GAO to conduct a study on the policies and activities of the ONC and must specifically focus on efforts related to patient matching.

* Sec. 4008. GAO Study on Patient Access to Health Information  Requires the GAO to conduct a study to review patient access to their own protected health information, including barriers to access and complications providers experience in providing access to patients.

*Additional Changes.  The new version does not contain the three-star rating system that was part of Senator Bill Cassidy’s TRUST-IT Act and included in a previous version of Cures.

There is good and bad in the IT provisions of Cures.  

I’ve written in the past that interoperability really means getting the information necessary for coordination of care to those who need it without too much difficulty.   You could read the Cures language as making available every data element for every purpose to every stakeholder with no effort.   That is just not realistic.

I recently spoke with the CEO of a leading EHR company who noted that he has committed 600 person years of resources to support the healthcare regulations already issued in the past 10 months.   Asking the EHR vendors to do something vague like support all registries and provide for “complete access, exchange, and use of all electronically accessible health information for authorized use under applicable State or Federal law” is like boiling the ocean with a lighter.   Although I applaud the GAO report on patient matching (and I support a voluntary national healthcare identifier),  I cannot support legislation that co-opts the agenda of developers to the point they cannot meet customer needs because they are too busy creating functionality mandated by Congress.

Over the next 4 years, you’ll find me serving the Governor of Massachusetts, the New England region, and multiple international governments.     I remain optimistic that the private sector will be allowed to innovate in response to demands from clinicians.    I will do my best to serve all stakeholders, working hard at every level of government to do no harm, as mandated by the oath I took as a doctor.

Thursday, December 1, 2016

Unity Farm Journal - First Week of December 2016

As winter approaches each year, we work hard to prepare the farm property for the cold, dark, snowy days ahead.    Weekends and nights are spent clearing brush, /storing all irrigation infrastructure, and doing the last digging/hauling/siftng before soil freezes solid.   At this point the barnyard,  trails and  the sanctuary next door are ready.   All farm equipment is freshly oiled and filled with winter-ready fluids.  We purchased a snow blade attachment for the Terex front loader since we’re responsible for snow removal on our 1/2 mile of local roads.   The Terex snow blower attachment is ready for paddock clearing and removing snow from those areas that a plow cannot reach.

Winter is a hard time for animals and we’re readying for new arrivals.   All three pigs (Hazel, Tofu, and Lunchbox) are now living together in harmony and we’re preparing for a potential fourth pig, Penny, who we’ll visit this weekend.   She’s a Yorkshire with a rough history and she’s underweight for her age (about 40 pounds at one year old).  We’ve been reluctant to take on Yorkshires because they can grow to 600 pounds.   What does a 600 pound pig do?  Anything it wants to!

We’ll also be meeting two groups of goats this weekend.   In December, three horses will arrive at the sanctuary - Amber, a 20 year old female Arabian; Sweetie, a 20 year old female Welsh Pony; and Pippin, a 30 year old male Welsh Pony.  

We’re being very careful to avoid over extending ourselves, our resources, and our community volunteers.   Every day we’re presented with a new rescue inquiry.

As a certified organic farm, commercial kitchen, and bonded farmer winery, we’re very familiar with legal paperwork.   This week we submitted our final paperwork to establish a new non-profit corporation - Unity Farm Sanctuary Inc, a public charity devoted to animal rescue and public education.    We’ve selected our initial board of directors, and established early funding streams to ensure the Sanctuary persists beyond our lifetimes.

Although it’s cold, we’re still having late fall rain and so the Shiitake mushrooms have be fruiting nicely.   Here’s what a mushroom delivery to the farmstand looks like

Now that Thanksgiving has passed, local businesses are donating their pumpkins to us by the pallet.   When a forklift loads a pallet of pumpkins into your farm truck, this is what it looks like.

Speaking of Thanksgiving, here’s what the traditional holiday meal looks like on an organic vegan farm - plates of local vegetables, Unity Farm ciders/beers, and a vegetable-based field roast.   No animal products of any kind, virtually no fats, and no processed sugars.  There is much to be thankful for in 2016.

Thursday, November 24, 2016

Unity Farm Journal - Fourth Week of November 2016

Happy Thanksgiving from Unity Farm!

A new pig has joined the herd - Lunchbox.  He’s 3 years old and has a remarkable personality.    He loves humans and is very good with children.   We’re gradually introducing him to Hazel and Tofu  through a livestock fence.   In a week or so, we’ll bring them together snout to snout once they have had the opportunity to learn each other’s smells and temperament.    Creating harmony in a pig herd is an art form and there’s a great deal of literature about it.   We’re seeing the expected behaviors - grunting/chewing, side stepping, and a bit of mouth foaming.

Here’s a photo of the pigs enjoying an organic Unity Farm pumpkin together on either side of a fence.

We’ve continuing to prepare the land between the Farm and the Sanctuary with new trails and roads.   We’ve chipped all our old mushroom logs to create a base for new trails.   The Sanctuary Road and Coyote Run are finished.   We’ll work on the Pond Trail and Pine Loop once we take ownership of the Sanctuary property in December.

Kathy’s vision is to create large paddocks in the forest between the two properties over the next few years so that we’ll eventually have a much larger animal rescue capacity.

All of this takes careful consideration of how all the creatures will interact in a community, ensuring we have the time and resources to offer each an enriching life.

For the moment, we’re planning to add two donkeys, two ponies, and a horse.  Although Kathy and I had significant horse experience as teens, that was 40 years ago.   We’re comfortable around all barnyard animals, but we're not experts in equine care.

 Choosing which animals to take on requires that we stay focused on our goals.  Here’s what Kathy wrote to the adoption specialist who we’re working with at the MSPCA Nevins Farm:

“The mission of the Sanctuary is focused on rescue and education. Three experienced program advisors to our project will make sure we do not take on more than we can handle with respect to health, fitness, and behavior of the various animals.

I have two good friends who are experienced current horse riders who will volunteer at our sanctuary.  My personal focus is not riding-readiness.  Temperament is important because we want leading and grooming to be educational options.”

We continue to study all the possibilities and likely we’ll soon take on two Welsh Ponies who will retire to the Sanctuary and be companions to each other.

This weekend we'll visit a rescue horse in Southern Massachusetts.   We're learning a lot about thoroughbreds, quarter horses, standard breds, arabians and Morgans as we expand our scope to include a more diverse array of inhabitants at Unity Farm.

Wednesday, November 23, 2016

The BIDMC CareKit app

The following is a guest blog post from Seth Berkowitz, MD, who authors many of the innovative apps in the BIDMC Crowdsourcing program:

Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School, has developed BIDMC@home, a new app for engaging patients using Apple’s CareKit and ResearchKit frameworks and the HealthKit API. The app provides a flexible framework to help patients manage their health from home, as directed by their physicians. The app will be piloted in several specific patient populations and will eventually be offered to BIDMC’s entire network of over 250,000 patients.

BIDMC@home provides personalized home monitoring in many different conditions. HealthKit allows the app to collect data from various sensors and 3rd party apps to gain a holistic picture of health and help prevent hospital readmissions. Together with HealthKit-enabled wireless devices such as scales and blood pressure cuffs, patients with congestive heart failure can use BIDMC@Home to monitor vital signs and symptoms. Daily fluid, sodium intake and important predictors of fluid retention, can also be imported via HealthKit. Connected thermometers allow patients with autoimmune diseases such as lupus and rheumatoid arthritis to better predict infections and monitor inflammation. Outpatient chemotherapy is associated with varied symptoms and side effects. The app allows these patients to better monitor their health during treatment.

BIDMC@Home simplifies complicated post-operative instructions given to patients after orthopedic surgery by utilizing the dynamic care card and allowing them to track their recovery. Major bowel surgery can place patients at risk of severe dehydration. Connected scales and electronic patient reported outcomes will help prevent complications in these patients in between visits to the doctor’s office.

The app contains several key functions:

Care Card:

Every patient has a customized care plan that is seamlessly synced from the electronic medical record via FHIR interfaces. All outpatient medications are listed and updated in real time when a provider makes a change. Patients are encouraged to adhere to their prescribed medication regimen and can also track their intake of “as needed” medications. Providers can also define a care plan for non-medication activities, such as: diet, exercise, sleep or other instructions tailored to their individual care.

An essential part of staying healthy is the plan and thought process laid out in the health care providers’ notes. All too often these are hidden in the silos of individual electronic health record systems. BIDMC@home harnesses the capabilities of the Health app in iOS 10 to serve as a secure, patient controlled, shareable database of medical records. Under the umbrella of the Open Notes initiative pioneered at BIDMC, patients will be able to view and download their physician’s notes from BIDMC, transforming their phones into true personalized health records.


As part of each patient’s individualized care plan, he/she is prompted to provide subjective and objective data to monitor health. These data include values that are synced via HealthKit from connected sensors or other apps (e.g. weight, blood pressure, heart rate, temperature, daily sodium intake) and subjective assessments. Using the ResearchKit framework, the app collects meaningful patient reported outcomes using simple questions (e.g. shortness of breath on a 0-10 scale) or more elaborate validated survey instruments.


To empower patients to take control of their own care, the app provides a dynamic graphing engine so that patients can see the relationship between measurements, medication adherence, or amount of “as needed” medications taken and the direct results. By reinforcing the relationship between treatment and outcome, we hope to reinforce positive behaviors and improve treatment compliance.


The app syncs with our secure messaging system and allows patients to quickly contact their care team members.

Thursday, November 17, 2016

Unity Farm Journal - Third Week of November 2016

This week we had the Supermoon - the largest/brightest moon since 1948 

The pigs enjoyed basking in the moonlight while rooting and hunting for grubs/worms.   Here’s a picture of hazel in the moonlight

Pigs are hedonists and there are three things that make them happy

1. Food
2. Warmth
3. Belly rubs

Here are a few pictures

Tofu enjoying a fall sugar pumpkin
Hazel stealing a piece of Tofu’s pumpkin
Hazel in the winter pig palace warming her posterior in the mid morning sun

A television film crew dropped by the farm this week to get closeups of the alpaca.  Here’s what it looked like.   The alpaca are demanding royalties.

We’ve racked our last cider of the season, and now all our fermented beverages begin their overwinter malolactic (secondary) fermentation until we bottle them in the spring.   We’ll continue to brew honey lager over the winter and we’re studying how best to scale up our capacity to produce 5 kegs a week to meet growing demand.

At this time of year we’ve harvesting lettuce, spinach, and carrots for ourselves and the animals.   We’re selling eggs, honey, and mushrooms.   We’re preparing the farm for winter, keeping every animal area clean, dry, and filled with warm bedding.   Our weekend work begins to shift indoors where we repair equipment, build new infrastructure, and catch up on paperwork.    We're also making Unity Farm soaps and lip balms from honey, wax, and organic herbs.

Our sanctuary plan remains on track and we’ll double the size of the farm on December 15.   We’re already beginning to plan events for the sanctuary - artists retreats, educational offerings, and infrastructure upgrades.    Five years ago we were living in a small cape home in Wellesley and tending a small community garden.   Who would have thought that we’ve been running 30 acres of agricultural production, caring for 150 animals, and producing organic fruits/vegetables/mushrooms while educating the public about sustainable agriculture.    Truly, the journey in life, and not the destination, is the reward.

Wednesday, November 16, 2016

What Does the Trump Presidency Imply for Healthcare and Healthcare IT?

Many organizations have asked me to comment on the impact of the Trump Presidency on Healthcare and Healthcare IT.    I served the Bush administration for 4 years and the Obama administration for 6 years.   I know that change in Washington happens incrementally.   There is always an evolution, not a revolution, regardless of speechmaking hyperbole.

What am I doing in Massachusetts?   I’m staying the course, continuing my focus on social networking for healthcare, mobile, care management analytics, cloud, and security while leaving the strategic plan/budget as is.

I have no inside information and no involvement with the Trump campaign/transition team.   From talking to people in Washington and reading publicly available resources, I believe there are 10 themes that will guide us over the next two years.

1.   It’s likely that some corporate and personal taxes will be reduced, possibly increasing the funds available for innovation.

2.   It’s likely that some regulations will be simplified, possibly creating more free time/attention span for innovation.

3.   It’s likely that free market competition will increase and some of the political infighting around issues such as Medicare’s inability to negotiate drug prices may dissipate.  I'm hearing that Medicare may be encouraged to negotiate drug prices in the Trump administration.

4.   As corporate taxes are restructured, we may see repatriation of funds currently sequestered offshore.   The tax cost of bringing such funds back to the US today is 40%.   It may be 10% in the near future.

5.   Although much has been said about replacing the Affordable Care Act, it’s likely that it will simply be amended to reduce the focus on Health Insurance Exchanges.  There will be no “public option” for health coverage.   Private payers will be encouraged to offer products across state lines.   Pre-existing conditions will still be covered.   Children will be covered on their parents health plans until age 26.

6.  Medicaid will be moved closer to the states.   States will have more funds to invest in innovation.   Since states will directly benefit from cost savings resulting from investments in innovation incentives will be aligned.

7.  FDA scrutiny of new products may be streamlined.

8.  FTC enforcement actions may be relaxed.

9.  NIH funding may be cut and projects like the Cancer Moonshot, Precision Medicine, and the Center for Medicare and Medicaid Innovation may be scaled back.

10.  Most importantly, the transition from fee for service to value based purchasing will continue unmodified.   This means that all the work we’re doing to improve quality, safety, efficiency, patient/family engagement, and population health will still be high priorities.

I recently spoke with administrators in Washington and they reminded me that although political appointees all resign on January 20th, career appointees will continue doing the work already in progress.   Regulation can be changed in the medium term, but legislative changes (even with a Republican House and Senate) takes a long time.    MACRA/MIPS is legislation.  The Quality Payment Program is regulation implementing MACRA/MIPS.   The career employees are on track to implement the Quality Payment Program as scheduled  2017-2019.

My advice is to remain agile, keep calm, and assume that many Obama era healthcare IT programs will persist.    Focus on reducing total medical expense, measuring quality across the community, providing stakeholders with tools that are valuable to them, spreading the burden of data capture among teams of caregivers, and enhancing interoperability.

Working together and staying focused, above the fray of politics, we can make a difference.