What Keeps Me Up at Night - Fall 2013

As Summer draws to a close, I have returned to my usual blogging schedule!

Now that Labor Day has come and gone,  I've thought about the months ahead and the major challenges I'll face.

1.  Mergers and Acquisitions

Healthcare in the US is not a system of care, it's a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers.    As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create "systemness" through mergers, acquisitions, and affiliations.   The workflow to support systemness may require different IT approaches than we've used in the past.   We've been successful  to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via  "magic button" viewing and state HIE summary exchange.   Interfacing is great for many purposes.   Integration is better for others, such as enterprise appointment scheduling and care management.   Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2.  Regulatory uncertainty

Will ICD10 proceed on the October 1, 2014 timeline?  All indications in Washington are that deadlines will not be changed.    Yet, I'm concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation.    Will all aspects of the new HIPAA Omnibus rule be enforced including the "self pay" provision which restricts information flow to payers?  Hospitals nationwide are not sure how to comply with the new requirements.   Will Meaningful Use Stage 2 proceed on the current aggressive timeline?  Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1.   With Farzad Mostashari's departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3.  Meaningful Use Stage 2 challenges

Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine.   One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems.   I have 25 developers and a part time analyst available for the task.   I've read every script and there are numerous areas in certification which go beyond the functionality needed for attestation.    Many EHR vendors have described their certification burden to me.    I am hopeful that ONC re-examines the certification process and does two things - removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.  

4.  Maintaining agility in a resource constrained world

At the same time we have ICD10 (a multi-million dollar burden), Meaningful Use Stage 2 (a multi-million dollar burden), the Affordable Care Act (a multi-million dollar burden), the HIPAA Omnibus Rule (a multi-million dollar burden), and increasing compliance oversight (a multi-million dollar burden), reimbursement is declining, sequestration is squeezing budgets, and fee for service medicine is transitioning to risk based contracts.    The ability of provider organizations to maintain operations while implementing all the new regulatory requirements in parallel is straining healthcare operations to their limits.   Safety, quality, and efficiency innovations are no longer possible because regulatory requirements  have consumed all available resources.

5.  Leading in real time

My organizations maintain hundreds of applications and thousands of devices with 99.9% reliability.    Rather than praise us for our diligence, the average user in 2013 wants to now why we are not meeting their needs .1% of the time.  When I do not respond to a request in 5 minutes or less, I'm asked if something is wrong.   Leadership in the era of Twitter is expected to be all seeing, all knowing, and omnipresent.   Strategic thinking, planning, and consensus building is challenging in a real time world that expects instant gratification.

I do not mean to sound pessimistic in any way.   All of these challenges can be conquered.   For nearly 20 years, I've led an IT organization that has continuously delivered miracles with 1.9% of the operating budget.   I am ready for the challenges ahead but wonder if mergers/acquisitions, regulatory uncertainty, MU2 certification challenges, resource constraints, and real time demands will create a set of constraints that are impossible to optimize.    Given that my role is to understand all the constraints and find a path forward, it's the Kobayashi Maru scenario that keeps me awake at night .   As Captain Kirk figured out, if the rules of the game make it impossible to win, the only answer is to change the game.    I remain the eternal optimist and am convinced that if we all work as hard as we can, the rules of the game will be changed so that we can succeed.

Unity Farm Keets (Guinea Fowl chicks) Available Now

Our Guineas have been remarkably fertile this Summer and we'll have 100 babies available for purchase.   They're $4 each.

Guineas are tick eaters and will rid your yard of many undesirable insects.   You will need a coop to keep them safe from predators at night.

Our first hatching of 20 is extremely healthy and we'll have another 30 hatching this weekend.

Although chicks are shipped in general, our experience is that the process is extremely stressful for them.    Anyone wanting guineas should contact us at khalamka@gmail.com for New England (Sherborn, MA) pick-up.  Here are the details:

Straight Run (M/F) Hatched 8/20/2013
Pearl Gray (standard dark color)
Pearl Gray Pied (white chest)

Colors possible (Pearl Gray, Pearl Gray Pied, White, Lavender and Lavender Pied)
2nd Hatch on 9/3/2012
3rd Hatch (last for the year) on 9/18/2013
All will be well feathered by the time cold weather arrives

$4 each or 10/$30

Building Unity Farm - Preserving History

Since Sherborn's founding in 1652, the land of Unity Farm has been adjacent to the town center.  In the past, the property has been a dairy, sheep paddocks, and part of a much larger farm.   As I've cut trails through the property I've uncovered old tools, old timbers, and numerous rock walls.

Along the Unity Farm Marsh trail are two particularly interesting sights - the Sherborn Powder House and the Old Dug Well/Windmill.

The Powder House
The Powder House for Sherborn was built by the town in 1800 so that gun powder could be removed from the public meetinghouse where it had been stored, much to the relief of concerned citizens.  James Bullard was appointed keeper and the building was constructed in a meadow overlooking the lane behind his house at 33 North Main Street.  Although the actual building was demolished in 1857, the site of the Powder House is on our property.    The circular foundation is still in place and the rocks used to build up the walls are lying adjacent to the foundation.   An ash tree has grown up inside the former building.   Today, railroad tracks cross Powder House Lane in Sherborn, so the Powder House is no longer publicly accessible.      I've cleared the area, connected it to our trails and will be adding National Forest Service-like signage to it soon.

The Old Dug Well
About 100 feet south from the Powder House is an old, hand dug, brick-lined well.   When I first found it, the well was filled with 5 feet of mud, wood debris and midden.   What do I mean by midden?   As I began to excavate the well, I found 10 old milk crates, hundreds of pounds of old unmilled lumber, rusted iron tools, and an old menu board, pictured below.    Although fragments of the menu board are missing, it appears to announce "Great Steaks" like the "Powder House Tenderloin", Sirloin, Round, etc.  The lettering appears to be from the early 1900's.   I've asked Historical Society members about the well and steak sign.  Their only guess is that it might have been related to the old train station on Powder House Lane (no longer there) that used to be the major transportation hub in Sherborn.

Next to the well, an old windmill (blades shown above) provided the energy to pump the well water uphill to sheep grazing meadows.  

Since the well has now been restored to be a fully functional water source, I built a cover for it from 6x6 and 3x5 lumber.   We do not want wandering deer (or wayward teens) to fall into the well.   Our Great Pyrenees may not be as communicative as Lassie if Timmy falls into it.

Building Unity Farm - The Guinea Fowl are Born

It's August in New England and although everyone in healthcare IT is consumed by Meaningful Use stage 2, ICD10, ACA, the HIPAA Omnibus Rule, and various compliance initiatives, it's also the time we try to take a few hours off before the busy Fall.   Although I'm not taking any vacation this year, I have reduced my writing schedule (hence fewer blog posts this month) and spent more time at Unity Farm.

This week our first 20 guinea fowl hatched and the keets (the name for young guinea fowl) are running around the brooder, eating, drinking, chirping, and sleeping.

Here's how we did it.

Guinea fowl are terrible parents.  They lay eggs in a community pile and one female incubates them all.   Unfortunately, they tend to lay in the forest near fox dens, fisher cat habitat, and coyote trails.   We've lost several females this Summer but luckily found the nests and gathered the eggs before they were too chilled to be viable.

We placed them incubators at 100F and 50% humidity.   The gestation period of a guinea is 26-28 days.

Automated egg turners slowly moved the eggs for the first 23 days.  Then we laid them flat in the incubator, making it easy for the chicks to peck through the shells.

On day 25, one of the larger eggs started to roll, crack, and chirp.    A few hours later, a piebald keet was born  (Keets come in pearl black, white, grey, and piebald).

On day 26 and 27, the rest of the eggs popped like popcorn with little keets running around the incubator.   About an hour after birth we moved them to the brooder, a larger space kept at 100F with ample food and water.

Three of the 23 eggs did not hatch (hence the expression don't count your chickens before they're hatched), which is typical for game birds.   After verifying that there were no signs of movement, I carefully opened the 3 unhatched eggs and found that all  had developmental issues and an early demise.

The 20 keets that hatched are amazingly active, large, and robust.   Our batch of keets last year arrived in the mail and we had quite a lot of attrition.  There are definite advantages to hatching your own poultry.

Animal husbandry is hard and Guinea Fowl can be challenging, as illustrated by this great article in the Atlantic.

At 4 weeks, we'll move the guineas to the coop, but keep them from free ranging until 12 weeks.  We find that 2 months in the coop gives the guineas a chance to mature and be able to defend themselves agains predators.  It also firmly establishes the coop as their home and they'll return to sleep there every night as adults after a day in the forest.

We've gathered nearly 100 guinea eggs from forest nests and all are in our incubators.  Although we can keep 50 or so in our coop and sheds, we'll sell the others to local farms.   Given the significant increase in tick-borne disease across the country. we believe that guinea fowl, nature's most efficient tick eater, will be very popular with homeowners in the rural areas west of Boston.  

Guineas have become such a regular part of our lives that I cannot imagine a day without them.  Looking out my home office window, I expect to see the guineas running by on their quest for food and camaraderie.

Building Unity Farm - The Trails

Unity Farm has a rich diversity of natural woodlands, wetlands, meadows, paddocks, and orchards.  The house and barn are located on an upland plateau surrounded by white pine, sweet birch, poplar, white ash, red oak, and red maple.   The woodlands to the south, west and north wrap the upper plateau.  The woodland zone includes a forested wetland that collects the upland water and directs it to the north via a swale.   To the east, the land is a grassy 6:1 slope from the top of the orchard to the edge of the forested wetland that connects to the meadow.

Over a mile of trails connects the natural features.    I've hand cut the trails with a Japanese sickle, Scandinavian Forest Axe,  and  Japanese folding saw.

Last weekend I added trail signs, made by the same company that creates National Forest Service markers.  Here's a virtual walk on the trails of Unity Farm:

Woodland trail
 This 1000 foot trail climbs through a fern grove and over a drumlin to a grove of old cedar that once lined a revolutionary war era pasture.  Old rock walls provide shelter for a variety of forest animals including foxes, fisher cats, opossum, skunks, and raccoons.     I've marked the trail every 100 feet with bird houses built from old cedar boards.   This year several busy Carolina Wrens raised their young in those houses.    A 12 foot bridge traverses the seasonal wetland in the lower portion of the trail.  I add two resting places along the walk - a painted bench at the base of an old pine and an Adirondack chair at the top of the drumlin.   An old Japanese stone lantern marks the end of the trail.   The Woodland trail connects to the Old Cart Path.

Old Cart Path
 Sherborn was founded in 1652 and town maps show an old cart path traversing Unity Farm, connecting surrounding orchards.   The Old Cart Path trail is 600 feet long and winds past our mushroom growing area, through a grove of sensitive fern, on its way down to our stream.   Another 12 foot bridge crosses the stream.   Along the way, a 30 year old teak bench sits in a sea of greenery next to a large pine tree.   This is one of the quietest and most contemplative places on the property.   The Old Cart Path connects to the Marsh trail.

Marsh trail
 We mapped our wetlands this year as part of preparing a general management plan for the property.   The Marsh trail is 800 feet long, starting and ending at our stream.   There are three 12 foot bridges along the path, carefully constructed to avoid shading native plants and to be completely non-intrusive to the natural landscape.   The trail passes an enormous old pine, a hand dug revolutionary war era well, and the site of an old windmill that pumped well water to supply the dairy farm that occupied our property in the 19th century.  The Marsh trail connects to the Meadow trail

Meadow trail
 A wildflower meadow borders the wetland and is home to woodchucks, ducks, wild turkeys, deer, and 4 of our beehives.    A 600 foot trail crosses the meadow and connects to the Orchard trail.

Orchard trail
 We created the orchard in 2013 and this 800 foot trail meanders between the orchard fence and the rock walls bordering the wetland.   The trail is lined with old cedar, maple, and oak.   Our Great Pyrenees enjoy running on this trail in search of rabbits, guinea fowl eggs, and deer.   A 6 point buck, a doe, and fawn graze along this trail, making for some interesting walks when 200 pounds of Pyrenees discover the deer (the dogs outweigh me by 35 pounds)

Although these trails have given us access to every portion of the property, there is still mystery to be found.  The forests, wetland, and fern groves are so dense that I'm constantly finding new artifacts,  animals, and plants.   Last week I found 3 intact Horlick's Malted Milk bottles from the 1920's on the Woodland trail, a fox den on the Orchard trail, and wild Concord grapes on the Marsh trail.   Building, maintaining, and walking the trails of Unity Farm could keep me busy for a lifetime.