Thursday, October 20, 2016

Unity Farm Journal - Third Week of October 2016

I’ve been in China this week, so Kathy has been running Unity Farm.    As usual, the farm continues to be an ever evolving and exciting place.  Here’s a typical email from her

“Many visitors were here today.   Our young intern was here helping out for an hour, then at 4:30pm someone dropped off a 5 year old pair of hens, then a person dropped by to spin honey from their hive.    You never know what each day will bring”

She’s received several more rescue animals this week and she’ll decide which animals which will live permanently at Unity Farm and which will be placed at other farms.    I’m working on a business plan for the Unity Farm Sanctuary, having learned a great deal about grants, fund raising, and the sustainability of sanctuaries from reading other’s experiences

We’ve been expanding our capabilities to receive an increasingly diverse array of species, such as birds that cannot be released directly into the wild. Here’s a picture of the new aviary we’re building.  I’ll finish it next weekend after I return from my travels.     We’ll be ready for various rescue birds once we receive our state license to host them.

Kathy has been tending our cider fermentation and the 2016  vintage is shaping up to be a very flavorful, well balanced product.     We have 500 pounds of apples left in the cooler and I’ll press them when I return.   Here's our new growler design.

We’re always learning about the land and the history of the landmarks we’ve discovered on the farm.   A few years ago, while clearing trails, I found a slate gravestone sitting in a grove of old cedar trees labeled

“James Bullard”
Died June 30, 1828
Age 66

Who was James Bullard?   He was “Johnny Tremain

When I was an elementary school student, I read the story of a fictional 14 year old living at the time of the revolutionary war and his impact on those events.   James Bullard was 14 years old in 1776 and he tended the gunpowder for the minutemen in the  Sherborn area.    On June 30, 1828 he had “apoplexy” and died instantly at a spot not far from our barn.   Apoplexy could be anything from a heart attack to a stroke.   At his funeral all the town families toasted rum in his honor, then shortly thereafter decided  to ban all alcohol from the town.    When James died, so did alcohol consumption in the town.    Here’s the story of the his gravesite at Unity Farm as written by a member of the Sherborn Historical society.

This weekend, I’ll be in New Zealand and Kathy will plant the 2017 garlic in our large outdoor beds.   I’ve promised that she can take a vacation when I return from my October travels.   Some people say they look forward to retirement so they can travel.   I’m not sure what retirement is, but I can only hope the travel is less!

Wednesday, October 19, 2016

The Quality Payment Program Final Rule

Many people have asked me to review the Quality Payment Program final rule, released on October 14, 2016.

Several summaries have already been written but your best bet is to rely on the CMS Quality Payment Program website at

Yes, the rule is still complex - over 2400 pages, of which more than 50% is the mandated response to comments made on the proposed rule.  The good news is that CMS has been very responsive to feedback, creating a transition plan for adoption, reducing the number of criteria and extending the timeline which enables iterative learning before large scale implementation.

Under the Quality Payment Program, clinicians have two approaches to choose from for reimbursement:  the Merit-based Incentive program (MIPS) and Advanced Alternative Payment Models (APMs).

The Merit-based Incentive program (MIPS) is a new program for certain Medicare-participating eligible clinicians that makes payment adjustments based on quality, cost,  practice improvement, and technology adoption while consolidating components of three existing programs—the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals.  MIPS focuses on quality (both a set of evidence-based, specialty-specific standards as well as practice-based improvement activities),  and use of certified electronic health record technology (CEHRT) specifically focused on interoperability and advanced quality objectives.

In the final rule's technology area, called Advancing Care Information (which replaces Meaningful Use for physicians), CMS reduced the number of measures from 11 to 5 .   CMS recognizes that technology, infrastructure, physician support systems, and clinical practices will change over the next few years, so over reliance on a highly prescriptive and broadly scoped certification rule must be avoided.

Think of MIPS not as four separate categories (quality measurement, cost control, practice improvement, and wise use of IT) but as a single program focused on rewarding clinicians for improving quality and penalizing clinicians for non-participation.   There are only a few ways to change clinician behavior - pay them more, improve their satisfaction and help them avoid public humiliation (like poor quality scores posted on a public website).  MIPS pays them more, consolidates multiple other government programs, and provides flexibility to give clinicians every opportunity to make their quality scores look good.

Advanced Alternative Payment Models (APMs) were created to gradually evolve the US healthcare system from volume-based to value-based care.   Instead of rewarding clinicians for ordering more tests, APMs align incentives to reward wellness.   APMs are not a mechanism to deny patients access to appropriate care.  Instead they incentivize clinician to deliver the right care, at the right time in the right setting, hopefully achieving good outcomes at lower cost.   They involve taking downside risk - if you spend too much, your income is reduced, aligning risk and reward for spending healthcare dollars.

There are many different kinds of APMs - the Shared Saving Program, Medical Home Models, and episode payment models for cardiac and joint care.

CMS is exploring development of a voluntary Medicare ACO Track 1+ Model for ACOs currently participating in Track 1 of the Shared Savings Program or ACOs seeking to participate in the Shared Savings Program for the first time. It would test a payment model that incorporates more limited downside risk than is currently present in Tracks 2 or 3 of the Shared Savings Program.

Which approach should you choose - MIPS or APMs?   That depends on the size of your practice, the tools you have available to support care management/population health, and your experience with different payment models.    For a comparative analysis of the MIPS and APM programs see

In previous posts, I lamented the impact of the proposed rule on small practices, the linkage to the 2015 Certification Rule and the burden of measurement/reporting.  Many organizations reported similar concerns.

What did CMS do in the final rule?


(1) created a transition year with an iterative learning and development period in the beginning of the program.  This is described in detail on Andy Slavitt’s blog as the “pick-your-own-pace approach”  
(2) adjusted the MIPS low-volume threshold ($30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients) exempting many small practices
(3) established an Advanced APM financial risk standard that promotes participation in robust, high-quality models i.e. creating Track 1+ which reduces overall downside risk
(4) simplified the  technology requirements and offered partial credit for progress on technology goals
(5) established of Medical Home Model standards that promote care coordination.

The rule is a final rule with comment – which means that there are numerous areas in the rule where CMS is seeking comment to inform  future rule-making, and that comment period is open for 60 days. Seek out those sections and send CMS comment letters.

This year I’ve spent time in the UK, Denmark, and China, so I’ve watched how a single payer system and a more uniform, government administered approach works for society.    Although it may be that the US will evolve to a more uniform healthcare delivery system over time (i.e. a few decades) there is no way such wholesale change is politically  possible in the short term among the heterogeneous stakeholders of the United States.

Think of the Quality Payment Program as the beginning of a journey.   Some of it will work and some of it will not.   Some reimbursement choices will be expanded and others discontinued.   As long as clinicians are given flexibility along the way, and the overall burden is kept at a manageable level, I’m willing to pilot some of these programs and see how it goes.     More to come as we get into the details of EHR certification (just the limited components we need for APMs), compute quality measures, and build analytic tools   CMS is listening and I thank them for it.

Thursday, October 13, 2016

Unity Farm Journal - Second Week of October 2016

Despite my international travels this week and next, the farm waits for no one.   150 creatures need food and warmth.   The buildings and infrastructure need tending.   The vegetables and fruits need harvesting.      Between Denmark and China, I returned to Boston for day to ensure everyone was healthy and happy.

The temperatures dipped to 31F and I tucked the pigs into their quilts, shut the barn door, and let the panel heaters raise the temperature of their pig palace by 10 degrees F.

The chickens and guinea fowl generate so much body heat that their coop was a cozy 50F

The alpaca and the Great Pyrenees love the cold so they basked in the dry evening not inside the barn, but under the stars in the barnyard.

The consistently cool temperatures have brought out all the colors in our swamp maples, oaks, and poplars.  Unity Farm is now at “peak”.  Here’s a view of the farm lane along the meadow.

Before I left for Denmark, I used the Terex front loader to clear a 12x24 foot area of the forest behind the barnyard for the aviary we’re building.   Our animal rescue activities include birds that need to be isolated or kept safe from predators.  The base of the new structure is 1 foot underground so no creature will burrow into it.    We’re applying for the appropriate state licenses to host pheasants and other rescue birds.

Our apple pressing efforts this year have been very successful with nearly 1000 pounds processed using our manual grinder and press.    The first batches are done fermenting and we’ve racked them into fresh sterile containers for secondary (malolactic) fermentation over the winter.

Our farm sanctuary planning continues and we’re designing the integration of a public farm educational and animal rescue center with the existing Unity Farm barnyard, orchard, and trails.   It’s an exciting time and we think 2017 will be a pivotal year for our activities.

While I’m away, Kathy will have part time help a few hours a day to do the tasks I would normally do early mornings and evenings.    She’ll harvest our mushrooms, lettuce, and remaining apples.   She’ll ensure all the animals return to their protected shelters at night.    She’ll keep the farm a vibrant place.   She's amazing.

The farm beckons in the Fall, but  IT duties call and there are miles to go before I sleep!

Wednesday, October 12, 2016

Dispatch from Denmark

Today I’m in Denmark speaking at a yearly national healthcare IT conference.  

Denmark is a remarkable country of 5 million people with a robust social support system.    Healthcare is provided for life as part of being Danish.   If you lose your job, generous unemployment benefits provide for the ongoing well being of you and your family.    Income inequality is among the lowest in the world (see the world mapped by income inequality below)

When people gather together in Denmark, there is a sense of common purpose and shared experiences.   The Danish call this “hygge” or coziness.

I spoke about the experiences of the Meaningful Use program, the evolving US reimbursement system, and the quest for innovation - especially in the areas of social networking for healthcare, mobile, analytics, and cloud hosting.

As I travel the world, I find the most societies are struggling with the same problems - how to improve healthcare quality while reducing cost, how to enhance safety and efficiency with technology, and how to improve the patient experience.

Technology is rarely the rate limiting step.   Instead the primary issues are workflow redesign and process improvement.

While in Denmark, I heard that government planners proposed implementing automation to save money by eliminating medical secretaries and other team members who would have shared the burden of data entry.   I explained that this would be "penny wise and pound foolish".   In the US,  40% of clinicians want to quit because they no longer practice at the top of their license, spending half their day on data entry.  Rather than expect a return on investment from staff reductions, a better approach would be to spread the work of new digital tools across a team of caregivers/support staff enabling all clinicians to be more productive doing direct patient care.

Denmark has taken a leadership role in many areas.   They have a single lifetime identifier for healthcare.   They have a nationwide registry of medications.    They have a single uniform consent and privacy policy for the country.   The US needs to follow their example in these areas.

I look forward to hosting my Danish friends in Boston to show them our work with telemedicine/telehealth and patient/family engagement.   I return to Boston tomorrow and then head to China on Saturday for a series of keynotes about innovation, emergency response, and healthcare leadership.   From China I travel to New Zealand to meet with healthcare leaders in Auckland, Christchurch, and Wellington.

Although I limit my international travel to just my “vacation time”, I relish the bidirectional exchange of ideas as we share our experiences, good and bad, with each other with the hope of making a difference in health.

Thursday, October 6, 2016

Unity Farm Journal - First Week of October 2016

What a year at Unity Farm: a plague of winter moth, a spring gypsy caterpillar infestation, deep drought, and maybe Hurricane Matthew, which is heading up the coast, might affect our foliage color and branch-falling.    Life on a farm is never boring.

Every October we press cider using the apples that were most successful that season.  This year our mixture is 40% McIntosh, 40% Cortland, and 20% Macoun.    Last weekend we hand pressed 250 pounds and created a cider with a ph of 3.3 and a specific gravity of 1.054 which will yield a finished alcohol by volume of 6-7%.   Although the drought created great stress in the apples, they are very flavorful and we extracted 2.5 gallons of fresh cider per bushel (42 pounds) we pressed.

After two weeks of fermentation, we’ll rack the cider off the yeast, and age over the Winter, bottling and carbonating in the Spring.

As Halloween approaches we always plant garlic and this year, we’ve created a 16’ x 16’ main garlic bed and three 4’ x 8’ satellite garlic beds.   The garlic will grow strong enough before the snow falls and then will become dormant over the winter, exploding with fresh growth in the Spring in time for a July harvest.

We’re starting to experience nights in the 40’s so we moved the pigs from the Summer Cottage to the Winter Pig Palace.   They now spend their afternoons with their bellies facing south to absorb the warm of the sun.    By nightfall they burrow in their hay under blankets and snuggle with each other to keep warm.

As the temperature drops, the last of the black swallowtail caterpillars is finishing its fall meals on dill, anise, and rue plants.   They’ll soon form a chrysalis and overwinter.    Our cornflowers will be filled with young swallowtails in the Spring

One of the most popular items we’ve sold recently at the farmstand are our “hyper-local” honeys.    We have nearly 100 hives spread in town around Sherborn.   The Wellesley honey has been particularly popular.  

Our work on the Unity Farm Sanctuary continues and we’ve signed the purchase and sale agreement, removing all contingencies.    This December, the real work begins as we start to create the educational center and enhanced animal rescue at Unity Farm.

One surprise this week.   Kathy went out the front door to collect eggs and what did she find - three around moms and a dozen new guineas.    Try as we might we have no idea where they nested.   As is typical our 60 guineas want to become 500 guineas every year by building secret nests in the forest.   The babies are warm and feed in the brooder and in 8 weeks, we’ll likely move them to a farm in Maine.

This weekend will be filled with more apple pressing and fermentation duties.  Next week will be a day in Denmark lecturing, then off to China for a week of policy and technology work before heading to New Zealand for an invited lecture.     Kathy and I  agreed that next Fall we’ll put a ban on all travel!

Thursday, September 29, 2016

Unity Farm Journal - First Week of October

The drought has taken its toll on the Fall color, with leaves going from green to brown then dropping off the trees.   The mornings are crisp - in the 50’s and the afternoons barely reach 70.   The shadows are long and the hoop house loses sunlight at 3pm.   The lettuces and spinaches are thriving in the early fall weather and the furry animals relish the cooler climate.

Each week is filled with harvest work and the effort to move Unity Farm Sanctuary forward.    We’re finishing the inspections and well testing of the adjacent property this week and hopefully will progress to a formal purchase and sale next week.    I’m already planning the new trails between the two properties - I’ll call them the Pine Loop, the Pond Trail, and the Coyote Path.    When I’m done, the combined farm and sanctuary will have 3 miles of trails.

The Sanctuary will have an educational mission with an animal care training area, a mushroom cultivation area, a flower CSA, a farmer winery/cider demonstration area, and sustainable agriculture instruction classrooms.

The new property will have 3 new paddocks and a 5 stall barn.   We’re already begin contacted by folks who have animals needing new homes.   Likely our first addition will be a pair of donkeys - one age 12 an one age 20.   They can live 30-50 years with the right conditions.   We’ve been offered sheep, alpaca, and goats.   We’ve thought about our ability to deliver the companionship, medical care, and quality of life needed by each of these species and we’ll probably avoid sheep, which bring different parasites and bacteria to the farm than the existing inhabitants.

The tomatoes are gone and the lettuce/spinach/carrots are thriving, but only in our beds with micxospray irrigation.   Those in outside beds are struggling since the 3 month period with virtually no rain has turned our once fertile river bottom soil into hardpack.  Here’s a New York Times article about our region

This weekend we’ll crush 250 pounds of Cortland and McIntosh apples for hard cider.  Next weekend we’ll do the same.    The following weekend, we’ll host a group of IT leaders and host the local 4H club to demonstrate cider making with just 120 pounds of apples.    This will be the last year we use a hand cranked apple scratcher to create Unity Farmhouse hard cider.

From now on, a 2 horsepower stainless electric grinder will enable us to mill 1000 pounds per hour.

For next season, I’ll likely build a 60F climate controlled fermenting area with enough tanks to support our goal of 300 gallons of production from 5000 pounds of apples.   We’ll still be a small producer but we’ll be efficient.

Wednesday, September 28, 2016

Social Media Guidelines for our Clinicians

We recently published this guideline at BIDMC based on the input from a multi-disciplinary working group.   I thought it might be useful to share with the community, since many healthcare organizations are at the early stage developing social media policies.

1.  Why do consumers interact with an organization’s social site?

In general, there is a perception gap between the reasons consumers interact with companies on social sites and why the companies think they do. (Source: IBM Report: From Social Media to Social CRM)

After discounts and purchases (not applicable to BIDMC), consumers ranked reviews and product rankings, general information and exclusive information as the top reasons they follow a company.

Companies ranked learning about new products, general information, sharing opinions, and reviews and product rankings as the top reasons they think consumers follow them on social sites

Reviews and rankings are important to consumers, so we track and respond to all reviews/messages we receive. The reviews are also a great way to capture feedback about patient experience on an ongoing basis.

We receive reviews on all our social media sites. Some are informal, like a tweet. Some are formal reviews, like on Facebook, Yelp, Google+, etc. BIDMC monitors all sites 24/7 using a social media dashboard.

To maintain our integrity, BIDMC follows the same social media guidelines as the universal online community. This means:

We do not delete negative posts. The only thing worse than ignoring a negative comment is deleting it.  It only serves to anger the patient/consumer more and give them reason to react by telling ALL of their ‘friends’ on social media about their experience. The exception is when a negative post uses hateful, obscene or discriminatory language.

We do not ask for feedback or reviews from patients. Sites like Yelp have rules. One among them: “Business owners should not ask customers to write reviews. Review sites work because consumers voluntarily write reviews.” This is why Yelp, Healthgrades, etc. are able to provide consumers with as much trustworthy information as possible. Research has shown that when the consumer realizes that reviews and feedback have been solicited or influenced, they stop using it.

2. How do we respond to reviews?

We respond to all messages—both praise and criticism.  When we receive a complaint:
We respond ASAP.

We don’t make excuses.  (“We were short staffed” or “It was an unusually busy day”)

We apologize for the experience.

We try to take it offline as soon as we can. We send a direct message to the reviewer.

We resolve the issue. We immediately connect with Patient Relations to alert them to the complaint so they can follow up.

3. Why do we apologize?

We have had a few instances when a physician has felt strongly about apologizing. Some physicians are of the opinion that apologizing is an admission of error which could lead to lawsuits.

We believe that enhancing communication reduces malpractice assertions, not increases that.

The Marketing team along with Patient Relations has established a process to manage complaints/negative reviews. Our standard response in most cases is: We are sorry that your experience didn’t live up to the high standards we set for ourselves. We will forward your message to our Patient Relations team. If you’d like to contact them directly, please call ....

4. What does a physician need to be aware of BIDMC’s social media policy?

There is risk associated with the use of social media because any content posted can reflect unfavorably on the physician as well as on BIDMC. A post conveys information about the user’s personality, values, priorities, etc. To avoid errors and prevent risks, BIDMC has created a set of guidelines to help our physicians navigate the world of social media. The full policy is available on the portal. Here are some highlights:

Physicians cannot accept friend requests from patients.
If a physician engages in a discussion about the hospital on a social site, she/he should disclose that they work at BIDMC. On personal feeds, if discussing BIDMC, clarify that the posts do not express the views of the hospital.
Physicians cannot offer health care advice on social sites.
Physicians must respect and follow HIPAA requirements. She/he can never disclose information about a BIDMC patient.
She/he cannot endorse products on social media
Physicians must never disclose proprietary information about BIDMC.
BIDMC does not allow individual departments to open social media accounts. On rare occasions, Twitter or LinkedIn accounts are allowed. The request to open a social media account must be approved by the Social Media Policy Committee.