Unity Farm Journal - First Week of April 2016

Our Spring projects are approaching completion just as the warm weather is about to return to winter.   Over the weekend it will snow and on Monday it will be 16F.

We’ve finished the new paddock, so now we have two pig areas

The Summer Swine Cottage , in the shade of pines with breezes coming off the drumlin.  It has a generous mud hole for wallowing

The Winter Pig Palace, facing south for maximum solar warmth.

In the next few weeks, I’ll move our mushroom cultivation shade house, which is no longer used since our mushroom logs are fully mature, to the summer pig paddock so they will have a 30 foot x 12 foot shaded area.    Hazel and Tofu are so smart and so social that they demand to be massaged, fed, and wrapped in blankets every every night.    Eating a pig is like eating a dolphin or chimp.  It’s hard to imagine how humans ever decided that killing a highly intelligent social animal for food was a good idea.

We’ve finished the blueberry netting on our early and mid blueberries.   We ran out of netting material and the late blueberries will have to wait until the next batch arrives in May.    We now have 3 dimensional coverage for 180 high bush blueberries and our gooseberries.   We planted them 3 years ago and so our crop this year should be very robust.

Unity Farm Honey Lager is one of our most popular products.   It’s made with 11 pounds of Unity Farm honey per keg.   However, we’ve had to buy the Cascade hops that combine with water, yeast, barley, and honey to create the amazing flavor.   Since we’re locavores, we really want produce the entire product on the farm and thus we’ve finished our first hops trellis.   In mid-April we’ll plant the Cascade hops rhizomes that will lead to enough hops two years from now for our Honey lager to be an all Massachusetts product.

We also bottled our Monastery Mead this week.   It's 14% alcohol, and made with all Unity Farm honey, water and herbs.

As a full Harvard professor, I’m required to spend 200 hours a year teaching.   This week, I drove the Umass Agriculture school in Amherst, Massachusetts to deliver a 2 hour presentation about mushroom toxicology, medicine, and mycoremediation (the elimination of environmental pollution with mushrooms).     It’s wonderful to experience the enthusiasm and energy of undergraduates who are in the early stages of forming their career goals.   Here’s the presentation I used.

This weekend will include more lettuce planting, mushroom log inoculation, trail clearing, and preparing for my next week in London, helping Dr. Bob Wachter advise the UK on national healthcare IT strategy.    I love London but look forward to a Summer in the paddocks instead of planes.

Evaluating Blockchain for Health Information Exchange

Yesterday, I read a New York Times article about a possible successor to Bitcoin called Ethereum, which provides a distributed database (no central repository) for the purpose of tracking financial transactions.

I immediately thought of the challenge we have turning silos of medical information into a linked, complete, accurate, secure,  lifetime medical record.  

Might blockchain technology be useful in healthcare?   I posted the question to my colleagues, Arien Malec (VP, Data Platform and Acquisition Tools at RelayHealth and the new Chair of the HIT Standards Committee) and David McCallie (SVP of Medical Informatics at Cerner)

Here is the dialog, reprinted with their permission.

John - Would a distributed database based on the blockchain idea b a way to aggregate health records?

Arien - Of course. But it dodges the hard part: network and business model.

David - I haven’t seen a compelling use-case for blockchain in healthcare yet, but I haven’t done a lot of digging.

I was impressed with a brief perusal of Ethereum.  They have build a blockchain “platform” that is de-coupled from the digital currency model.  Reportedly, a lot of companies are using Ethereum for internal projects – any place where you need to “move value around and represent the ownership of property” (as they put it.)

But even with their platform thinking, it still sounds a lot like money:

“This enables developers to create markets, store registries of debts or promises, move funds in accordance with instructions given long in the past (like a will or a futures contract) and many other things that have not been invented yet, all without a middle man or counterparty risk.”

So, go out there an invent those things….

Arien - In theory, one could use the blockchain to store health records and provide proof of provenance, etc.

But like this blockchain ridesharing company. there’s no compelling use case – that’s why I said the hard parts are network and business model.

To put another way: where are the anonymized drug markets for healthcare that drove Bitcoin?

David-  I think a blockchain might work as part of a decentralized “health record bank” (HRB) model where there was no centralization of authority or provenance for each consumer’s record.  Every time a provider makes a “deposit” to a patients HRB record, the deposit could be annotated and verified by the blockchain.  On presentation of the consumer’s aggregated record to another physician, the blockchain could be used to verify that nothing had been tampered with.  It might even be possible to verify that nothing had been excluded?  Not sure about that point.

The blockchain wouldn’t contain the record, but could be used to verify that the record and provenance were tamper-free.

Sort of an Uber-PHR.  Pun intended.

Arien - Yes, that’s exactly what I was describing. And again, the technology is neat, but why would anyone use it?

For Bitcoin, started as an loose alliance of Cryptonomicon-dreaming anarcho-libertarian-techies-goldbugs who wanted to disrupt the power of states on the economic system, then the real killer app was darknet drug markets. The first was enough to establish the market; the second was enough to make sure it didn’t go away.

It’s the same problem with Ello, which was going to disrupt Facebook, but worse, because there was a natural initial Ello community (analogous to the BitCoin techno-anarcho-goldbugs) and there isn’t for the blockchain HRB.

The lesson: network building has to be primary and technology secondary. That’s why we started CommonWell, and why Argonaut has been successful.

David - Well, I think the folks who believe in Health Record Banks might find this useful. They (HRBs) have a terrible problem around trust — doctors don’t believe the patient-provided record is complete or tamper free.  Solving that problem (without blockchain) requires lots of centralized services – which are too expensive for anyone to want to pay for. Ergo, no real world HRBs.

But what if any HRB provider simply aggregated blockchain-signed “deposits” of the record from the patient’s physicians?  Then any provider could consume the record with trust that it was (complete?) and tamper-free.  (Each HRB provider would deliver the record via a SMART app, etc.)

(I’m unclear on the “complete” part — there might be some requirement that actual payment for services creates the blockchain record?)

Something like this might be a valuable enough use-case to explore?

Arien - OK, let’s assume the existence of a working and good blockchain implementation of an blockchain Health Record Bank (bcHRB) and a SMART app that serves as the bcHRB adaptor.

Argonaut, SMART, etc. gives us the ability to install the adaptor on every EHR in the country without needing to coordinate (yay! Argonaut).

OK, now what? We need the thing that starts up the network, because bcHRB is definitely a network-effects service. Doesn’t blockchain require us to distribute processing, like BitTorrent? But who pays for the compute time? (In BitCoin, the miners pay for the processing, with value based on mined bitcoin).

OK, maybe (hand waving) the SMART apps also supply the compute, which means they cost something, which means I need to pay for them? Maybe each bcHRB SMART app is hosted on Amazon VMs that supply the compute nodes? Also, I need to coordinate a bunch of people using the bcHRB in a community so that anyone gets value, and I need to make sure there’s enough value each time a provider hits the SMART app.

Back to network building again.

David- I’m getting over my head now, but I think in BitCoin, it’s only the gold miners who have to do lots of computing.  For individuals who simply want to trade coins, there is no serious processing.  (There is some network overhead to download the chain, but the processing is modest.) For example, I was able to buy a bitcoin, download a wallet to store it, and then purchase things.  It didn’t cost me anything other than the purchasing the initial coin. No serious mining, if all you want to do is use the network.

And any group who creates a blockchain from scratch can elect to pre-seed the network with as much “gold” as they want.  The Ethereum people gave out 20M coins to the folks who volunteered to develop the code.

So  I think “mining” is irrelevant to the HRB model since the chain is not carrying around an inflatable currency – it’s simply carrying around a complete record of all “deposits” of data to the bcHRB.   Each deposit is eventually verifiable to anyone who wants to sample the chain. Maybe the way to think about it is that anyone who has created a snippet of medical data can “deposit” it into the bcHRB network for “trading” securely with anyone else.

I would envision that the chain verification costs (which I think are very modest) would be borne by the folks who use the data – for example, the providers who access the record, or researchers who get your permission to use your data.

But I don’t know enough to be very sure of any of this!

And it might be possible to build something functionally equivalent without any blockchain at all.  But as soon as you start talking about certificate authorities and PKI infrastructure and such, you get into centralization and coordination overhead. Which is what BitCoin supposedly avoids.

Arien - To summarize:

Working blockchain systems require a set of compute nodes.
Those nodes verify the transactions, and (partially) hold the complete history of blocks.
In BitCoin the nodes are providers by BitCoin miners, who essentially get paid for running compute (mining == blockchain transaction verification)
In bcHRB, the compute nodes must be supplied by somewhere
BitCoin solves the “who runs compute nodes” problem by creating an economic incentive to do so; the same problem must be solved by bcHRB by ??

 I think David and I are saying the same thing: the compute costs are borne by the SMART app users, which is where I got to as well, which is how I got back into economics and network building.

John - I'll reassure the industry that we do not have attention deficit disorder and that we're still laser-focused on FHIR, enabling infrastructure, and governance.   Blockchain might solve one of the trust /data integrity problems we've that folks like Gary Dickinson have raised at HIT Standards Committee meetings.    Definitely worth further thought.

Still Here!

I am still here and will do a huge post tomorrow.... Still kickin well as a matter of fact!

How the Candidates Can Weigh In on Population Health

Watching March Madness (Go Villanova!) ads and the accompanying Political Silly Season news have alerted the Population Health Blog to the very real possibility that its state's late primary may play a role in the presidential sweepstakes.

While the PHB ponders what to do with its vote, it naturally thought about the candidates' positions on "population health." 

In no particular order and as a public service to the campaigns' search for talking points (and "dog whistles"), the PHB offers the following statements for their consideration, just in case the topic comes up......

Mr. Trump: Believe me, I've studied this far greater than anyone else and population health would have terrible ratings if it weren't for me.

Bonus question on electronic health records (EHRs): We have to EHR how bad it was a disastrous deal amateur hour believe me.

Mr. Cruz: The words "population" and "health" do not appear in the U.S. Constitution and this will end on day 1 when I become president.

Bonus question on EHRs: I cannot find the letters "e," "h" or "r" in the U.S. Constitution either, and it's not just because of the handwriting.

Mr. Kasich:  We did population health in Ohio when I was governor and while I chaired the Ways and Means Committee in Congress

Bonus question on EHRs: We did EHRs in Ohio and while I chaired the Ways and Means Committee in Congress.

Ms. Clinton:  We will build on the success of Obamacare by investing in population health through legislation that offers a tax credit to offset its cost that will be available through the exchange to assure that all families will not exceed a premium threshold under current law while incentivizing expansions of the program through all 50 states with a matching initiative over several years.

Bonus question on EHRs: I never knowingly sent confidential patient information or received anything marked HIPAA protected at any time. But under my plan, physicians will be able to use private email accounts to communicate with their patients.

Mr. Sanders: Population health, like a college education, solar power and frozen yogurt is a basic human right.

Bonus question on EHRs: That too.

Not to be undone, two other recent fixtures in the PHB television universe have weighed in on population health....

Charles Barkley (taking a break from his half-time college basketball commentary): It's turrible that people see that (unintelligible) Krispy Kreme that don't understand how if (unintelligible) people have eaten too much.

Joanna Gains of HGTV's Fixer Upper (a PHB spouse refuge from the TV craziness): Let's face it: Fixer-uppering chronic conditions with population health is possible with the affordable use of vintage twists that accent an existing space and give an illusion of depth with a favorite hue.  Try some mottos, mirrors and oversize remnants that group together and transform drabness to healthiness.

The Latest Health Wonk Review Is Up!

A straightforward summary of savvy health policy blogging awaits you over at ACASignups.net.

 

This HWR is timed with the sixth anniversary of the Affordable Care Act.  Topics include narrow networks, assisted suicide, misprescribing, balance billing, healthcare workplace violence, moonshots and the controversies over morcellation.

No association, or cause and effect?  You be the judge!

Unity Farm Journal - Fourth Week of March 2016

I’ve returned from China and re-established my daily routine on the farm.  In my absence Kathy kept the animals safe and warm.   She watered and nurtured all the indoor and outdoor crops.   She served as point of contact for all the people in our lives.  She's remarkable.

All is perfect on the farm and it’s as if I never left.

Here’s what the hoop house beds look like as of the last week of March.

We had one last winter storm this week with 4 inches of wet sticky snow.   It melted quickly and the weather cleared with brilliant red sky at night.

Now that spring is here we’re completing those projects that require dry, thawed ground - building our summer pig paddock, putting up the blueberry netting, repairing fences, and pounding the poles for the hops trellis.  

The creatures on the farm are glad that all the humans have returned.   The pigs are getting the belly rubs, the dogs are getting their runs, and alpaca are getting their chopped alfalfa/molasses breakfast.

Soon the Shiitake mushrooms will begin to fruit and we’ll bottle the cider which has mellowed over the winter.  

I look forward to a bit less travel and a bountiful Spring in the months ahead.

CareKit as an Enabler for Patient Generated Healthcare Data

As we move from fee for service to alternative payment models/value-based purchasing we will increasingly measure our progress based on outcomes and total medical expense.

HealthKit was an enabler that led Beth Israel Deaconess to create BIDMC@Home, an iPhone and iPad app that uploads internet of things (blood pressure cuff, glucometer, scale, activity, sleep data etc.) to our electronic health record.

CareKit, announced by Apple this week, takes us one step further on our wellness-focused journey.

Our vision is that objective data such as weight and blood pressure needs to be combined with subjective data such as activities of daily living, mood, and adherence to care plans in order to create a true measure of outcome.

If you take  your beta blocker for blood pressure control but feel listless and unmotivated, that is not a good outcome.

Apple’s middleware (HealthKit, Research kit , Carekit) has enabled us to connect devices in BIDMC patient homes and this Summer will enable us to collect answers to clinician generated questionnaires with dashboarding of the subjective and objective combined results.

We believe that mobile devices such as iPhones will become the predominant means by which patients interact with BIDMC.    Your phone will be the repository of your medical record, the means by which you collaborate with your provider, and the vehicle for submission of data to your care team.

Today, 80% of all BIDMC publicly available resources (websites, portals) are accessed via mobile devices.  The desktop is dead.   The phone is the future.

Kudos to Apple for enabling simple integration of devices in the home, collection of patient provided questionnaires, and bidirectional exchange of care plans.

I know that the current FBI/Apple security issues are controversial, but if we’re going to use the phone as the means for patients to coordinate healthcare, we need to ensure data integrity.   I support the idea of government entities obtaining cloud-based backups of devices when courts grant subpoenas.   I do not support the idea of compromising the integrity of phones when they are serving as the link between patient devices/patient sourced  healthcare data and providers.

The combination of sensors in the home, patient/family engagement, and security/data integrity is the secret to success in alternative payment models.   We look forward to piloting several new apps in 2016.

Busting Through the Healthcare Performance Frontier

Breakthrough!

The costs of business performance - for example, customer delight, reputational excellence, high worker satisfaction, workplace safety, leadership diversity, environmental sustainability or reducing social disparities - are typically viewed through the lens of a zero-sum game. 

In this classic world view, achieving profitability means cutting performance, while pursuing high performance reduces profits. The relationship between the two variables can be displayed as a curve:

Population Health Blog readers can find out more about this here.

Most firms in the real world operate on the "A" curve.  Different firms under different circumstances make dozens, if not hundreds, of decisions on a day-to-day basis involving trade-offs that move them along the curve that extends along the profitability and performance continuum.

Examples of healthcare companies that moved up on the curve at the expense of performance include the Veterans Administration and Turing Pharmaceuticals.  At the other end of the curve, the understandable unwillingness of some hospitals to walk away from their community service obligations may have led them to bankruptcy.

The "B" curve represents the theoretical limit for greater profitability and performance using the current business model.  In other words, as companies maximize all opportunities and minimize all inefficiencies in their existing business models, they can move the curve up and to the right.  That is what all management, executives and boards can define and aspire to.  That "B" curve is known as the "performance frontier."

Examples of healthcare companies that moved toward the "B" curve? You can find more about them here.  If they're hospitals, they fill beds with short lengths of stay and high patient satisfaction.  If they're clinics, they maximize billing revenue and minimize waiting lists.  If they're an ACO, they manage risk by contracting for an actuarially optimum population while pursuing the Triple Aim.

  

The "C" curve beyond the established frontier is what becomes possible with transformational innovation, superb leadership or both. Examples outside of healthcare include Apple under Steve Jobs and Tesla under Elon Musk. Firms that create value by inspiring employees, new products and innovative processes not only benefit from even greater profitability, but offer enhanced performance. 

In "C" level healthcare settings, the top-line growth and decreasing costs would be accompanied by better measures of customer/patient well-being, community burden of disease, worker engagement, leadership diversity and improvements in social determinants of health.

While the Population Health Blog eagerly awaits reports of frontier-busting healthcare providers, it offers a few observations:

1. Healthcare organizations have generally not done a good job in defining and measuring their performance metrics.  They've also not made them part of the C-suite's DNA or placed them prominently on their governing boards' agendas. If they did, breakthroughs would become more likely.

2. The EHR's primary functions of billing and documentation will never get healthcare organizations to the C curve.  This is not part of a breakthrough strategy.

3. In contrast, big data, risk stratification, mHealth and machine intelligence have the economic/business potential to identify risk, channel the right care, circumvent high cost service options and rationalize decision-making, but could also increase performance through the engagement of consumers, increasing access to more care options, reducing disparities and minimizing provider busywork.  These are the ingredients for a breakthrough to C-curve level performance that is only just beginning.

4. By the way, another ingredient for high healthcare provider performance can be found here.

5. Last but not least, the leadership of many innovative health technology companies already intuit much of this.  They're looking for partners that are not just looking for "B" level performance, but want to bust through the performance frontier. 

Image from Wikipedia

Unity Farm Journal - Third Week of March 2016

Kathy has been running Unity Farm while I’ve been in Texas and China.  The weather in Sherborn has been mild with light rain.  The first round of newly germinated seeds is planted in the hoop house and enjoying the warmth of early Spring,  Kathy is watering everything at the end of the day to keep the seedlings moist.    The Rex Boston , Buttercrunch Bibb and Nancy Bibb lettuce is almost ready to harvest.

Carrots, beets, spinach, peas, and beans are growing fast.   The tomatoes, eggplant, and pepper seedlings are nearly ready to move from the germination trays to 4 inch jiffy pots.

All the creatures are doing well, although the dogs and pigs miss me.   I’m the one who meets them on their own terms - crawling through mud, rolling in hay, and petting bellies while rubbing noses.   Kathy is a good petting proxy, although she remains standing.

Kathy also tucks in the pigs every night.   Here are two pigs in their blanket

The geese continue to defend their territory chasing the ducks and chickens from their nests if they get too close.   Our geese are very kind in general, but we’ll have to watch their “spring fever”

The driveway project is beginning and the 25 year old asphalt is being scraped away today so that a new gravel bed can be installed and allowed to settle for a month.  It’s great that we left driveway rehab until the very last, since the truck traffic that accompanied the building of Unity Farm infrastructure over the past 4 years was rough on it.    At this point, we’re to the point we can just run the farm, reducing the cost and effort of creating new things.   For a summer that includes a wedding, a bountiful harvest, and adding a few hundred more Shiitake logs to the woodland crop area, fewer construction projects will be welcome.

I fly from Hong Kong today to Los Angeles to help my mother with home maintenance and keynote the American Dental Association conferencing where I’ll offer thoughts on the ideal shared dental/medical electronic record.   Then home on Monday morning.   No more travel until Friday in Canada and next week in London.  Logan airport is my second home this Spring.