Building Unity Farm - Water management

I was recently asked how we manage irrigation at Unity Farm during the peak of Summer heat.

Although we have a stream running through the farm, it's part of a protected wetland, so we do not use it for irrigation.

Our water source is a 300 foot deep well that consistently produces 7 gallons per minute all year long.   Sherborn was founded in 1652 and was initially called Bogostow ("Bog's town") because of the many streams, ponds, and wetlands.   Our well has the benefit of being at near a drainage swale an nature keeps the aquifer seasonally recharged.

However, irrigating acres of orchards, paddocks, and produce as well as meeting the water needs of the 3 generations living at Unity Farm via a 7 gallons per minute well takes careful planning.

Here's what we do:

In 2012, we replaced the 18 year old well pump, wiring, and control system to give us the best infrastructure possible.   We also replaced the pressure tank.   The water is so chemically pure that it does not need a filter, a settling tank, or treatment of any kind. We were able to retire all the water treatment equipment that was initially installed after the well was drilled.   We placed digital flow gauges on the internal and external water mains so we can measure our water use and rapidly identify any unexpected variations such a broken pipe or leaking valve.

As we designed our animal and crop areas, we incorporated over 50 zones of irrigation controlled by two Hunter irrigation controllers, that enable us to selectively apply drip irrigation or low volume rotors to each area based on rainfall, plant maturity, and seasonal conditions.

For example, 7 gallons per minute can supply 420 one gallon per hour drip heads.   For each blueberry zone, we ran 400 feet of drip hose containing built-in one gallon per hour heads spaced every foot.   With two heads per plant and twice weekly 30 minute waterings, each plant receives 2 gallons per week precisely targeted to the roots.  We have 7 of these zones, running on Wednesday and Sunday nights between midnight and 3:30am.

Our pastures and paddocks have 23 zones of 4 low flow 1 gallon per minute rotors.   We run these for 10 minutes between midnight and 4am on Tuesday, Thursday, Saturday.

We tend to be generous with water to new plantings and parsimonious with water to well established plants.

We also have two rain sensors that automatically shutdown all our watering systems whenever more than half an inch of precipitation falls within a 24 hour period.

In summary we have

Crop zones
23 low volume rotor zones for pasture
7 drip lines for berries

House and Barn zones
8 low volume rotor zones for paddocks
4 drip lines for foundation plants around the house
11 low volume rotors zones for landscaping

We've also placed seven 75 foot hoses around the property for selective hand watering, cleaning, and animal care

From 1986-1993 we ran a vineyard on an arid mountaintop in Northern California and developed all the skills needed to carefully manage an agricultural operation from a well with limited capacity.

We've had record heat this season.  With targeted use of drip, rotators, and hand watering, everything is thriving on Unity farm.

Dispatch from Osaka

This week I'm in Osaka keynoting the IEEE Engineering in Medicine and Biology Society annual meeting.

Dr. Hiroyuki Yoshihara, my colleague from Kyoto University, hosted a pre-conference workshop on the state of EHRs throughout the world.   For years I've said that the challenges of EHR adoption and healthcare information exchange are the same in every country.    This workshop confirmed my impressions.   Speakers from Japan, New Zealand, and Brazil each spoke about issues such as:

Do we centralize data from multiple EHRs into a single repository for care coordination, patient engagement, and research?  Or do we create federated options with just in time data sharing from distributed EHRs?   The answer is that every locality approaches the problem based on requirements and policy concerns.   There is no one right answer.   Care coordination works well with distributed approaches (pushing summaries, pulling summaries, viewing external records) but analytics for population health and quality measurement benefit from data aggregation and normalization.

Do we accelerate change via top down government programs or bottom up industry driven initiatives?   The consensus was that top down, standardized, regulated approaches may temporarily slow innovation but they are effective in promulgating widespread adoption.   In the US, we've tripled adoption of EHRs since HITECH.  

Do we issue a national patient identifier (required or voluntary) to improve the accuracy of healthcare data aggregation?  Every country has different policy concerns and varying cultural tolerance of government mandated programs.   However, there was widespread agreement that an identifier for healthcare, required or voluntary, would make healthcare information exchange and analytics easier.   A curated national provider directory is also desirable.

How do we ensure data is comparable across multiple EHR systems?   Should we adopt detailed clinical models such as the work of the CIMI effort?  There was widespread agreement that vocabularies and clinical models are foundational to semantic interoperability and data aggregation.

Finally, how do we protect privacy?  Issues of consent, metadata, and de-identification are important throughout the world and approaches are highly variable based on culture, privacy laws, and regulations.   There is no single right answer but all agree that patient mediated exchange in which the patient is steward of their own information addresses many of the concerns.

My keynote today will focus on the grand challenges facing all engineers, informaticians, and policymaking professionals.  The five topics above - ubiquitous healthcare information exchange, universal adoption of standardized EHRs, accurately identifying patients/providers, creating foundational semantic interoperability tools, and protecting privacy are important worldwide and I look forward to solving them in our generation.

The FY14 BIDMC Information Technology Budget

Beth Israel Deaconess Medical Center runs on an October 1 to September 30 fiscal year, so Summer is
always a time of capital and operating budget decision making.

We've finished our FY14 capital budget submission and requested $10.7 million to fund all the needed infrastructure/applications supporting 3000 doctors, 22000 users, and a growing 1.2 billion dollar clinical enterprise.     This breaks down into $7.5 million for general operations, $3 million for security/regulatory initiatives and $210,000 (plus a $1.3 million FY13 carryover) for ICD10.

We've finished our FY14 operating budget submission and requested a base budget which is flat compared to FY13.   However, we have added two special operating budget requests - $2.6 million for security/regulatory initiatives ($1.3 million in new FTEs, $1.3 million in purchased services),  and $4 million in ICD-10 related costs.     Our total IS expense will be about 2 percent of the operating budget of the entire organization.

It is interesting to note that like many CIOs, more and more of my budget is directed to government mandated initiatives.  I've published the graphic above previously which shows what a healthcare CIO must do 2010-2015 -  Meaningful Use, ICD-10, HIPAA 5010, Physicians Quality Reporting Initiative, Value Based Purchasing, and Affordable Care Act/ACO formation all while ensuring appropriate protections are put in place to comply with the new HIPAA Omnibus Rule and increased Office of Civil Rights enforcement.   Also, there is an uptick of audits of all kinds motivated by federal, state, and internal risk reduction mandates.

My modest budgets are not a sign of unwillingness of the organization to allocate resources to IT - they are a function of the budget realities facing all healthcare organizations.

The work that we do is a function of time, scope, and resources.    As I reflect on the external pressures all CIOs face in 2014, change is accelerating, reducing time to complete projects.   Scope is increasing as healthcare moves from fee for service to global captitated risk.    Resources are shrinking with increasing pressure to reduce reimbursement, merge/acquire/affiliate, and overall reduce total medical expense associated with the care we give.

We all need to be very careful that CIOs and their staff do not approach the breaking point as the requirements for time, scope, and resources (FTEs, capital, operating) no longer align supply and demand. As I discussed in a previous blog post, we're moving forward diligently to inform the Board and senior management about the cost of every new project and deal.

Building Unity Farm - Creating a Brand

As we move from the farm building stage to the farm operations stage, Kathy and I are turning our attention to the basics of running our farming business.   We've filed articles of incorporation (Unity Farm LLC), created a formal land management plan for review by the town of Sherborn, built basic processes for recording income/expenses, documented options for selling our products and formulated a multi-year strategic plan leading to full recognition as an agricultural enterprise.

Creating a brand is an important step for us as we begin to build awareness of our apples, honey, mushrooms, alpaca fiber, handmade soap, and blueberries.  This morning I heard the 1970's New Seekers song "I'd Like to Teach the World to Sing" and it comes very close to the Unity Farm vision (replace Turtle Doves with Guinea Fowl)

"I’d like to build the world a home
And furnish it with love
Grow apple trees and honey bees
And snow white turtle doves"

Since that song is so closely associated with soft drink sales, we'll need another approach.

At the entrance to Unity Farm, a large specimen-quality sugar maple greets visitors to the property.   We've used its silhouette, shown above, to create  a logo and label for the farm.

For individual products, we'll use silhouettes of  apples, bees, Shitake mushrooms, alpaca, etc providing us name recognition and a standard labeling platform for everything we sell.

We have a Facebook page and we'll create appropriate twitter, pinterest, and other social media sites.

We've already collected this season's alpaca fiber and are spinning it into wool.   We're harvesting our first honey over the next few weeks.   We'll have our first berries in August and apples in October.   Our quantities of everything this first year will be very limited.   Likely our first real sales and the possibility of a "mushroom CSA", selling guaranteed shares of Shitake mushrooms, will be in 2014.

In the meantime, we're continuing farm development.  We'll finish the hoop house (a kind of plastic sheeted green house) in July and have another mile of forest trails completed by the end of Summer.    We're also picking peas and strawberries from a nearby farm, making our own jam as we await the maturity of our own berries and other produce.

I'm off to Kyoto this weekend, so my next post will be dispatch from Japan, where I'm keynoting the IEEE conference this year.

Affiliation Planning

Many healthcare organizations  are discovering that accountable care reimbursed via global captitated risk contracts requires more primary care physicians and a more tightly coupled delivery network including suburban hospitals, home care, and long term care.   Affiliations, mergers, and acquisitions are accelerating to meet these needs.

From an IT perspective how are to respond to this organizational change with agility and efficacy?

We could rip and replace everything everywhere and mandate a single vendor solution for every workflow at every new location.

That would create standardization, but it would also consume more capital than we have at time when Meaningful Use Stage 2, ICD10, and compliance requirements have already committed all available IT resources.

A balanced approach is to enumerate the workflows we need to support and then build upon existing applications and infrastructure to automate priority processes that improve quality, safety, and efficiency.

In the past, we've used web-based viewers,  health information exchange, registries/repositories, master patient indexes, and secure email to link together organizations and coordinate care.

Can we share every data element for every purpose in every circumstance?   No.   Can we rapidly achieve "good enough" at low cost.   Yes.

Our solutions to date have been project based - implementing those point solutions that best fulfill a specific affiliation.   The pace of change is so intense that we need a more scalable solution - templates for new affiliations, mergers, and acquisitions.

What services do we offer?  What services do our new partners want?  What do we centralize?  What do we federate?  What do we change and importantly what do we not change?

Over the next few months, we'll do the following

1.  Ask IT infrastructure and application managers to list the services they have been tasked to provide in the past when new affiliations have been formed

2.  Ask existing affiliates and new affiliates about their experience during the partnership process.    Inventory their existing applications and their plans for upgrading/changing them.

3.  With a sense of supply (the services we offer) and demand (the services desired), we can create templates for affiliations, mergers, and acquisitions - a kind of Chinese menu that will enable us to rapidly develop FTE, capital and operating budget requests when new partnerships are planned.

Sometimes I'm asked to budget for projects that are not yet formalized, often with ill defined scope.    If I could present a set of templates to the Board and Senior management noting that partnerships fall into three categories - small, medium and large, each with an estimated price tag, I could craft a yearly operating plan and capital budget that includes x smalls, y mediums, and z larges, ensuring promises made are backed by the people, funding, and attention necessary to support timely delivery.

I will post my templates once they are developed.

If any of my readers have developed such templates, I welcome the opportunity to review them.