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The Cybersecurity Market Is Consolidating

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4 Tips to Protect Your Information During Medical Data Breaches

As the companies we trust with our data become more digital, it’s important for users to realize how this affects their own cybersecurity. Take your medical care provider, for instance. You walk into a doctor’s office and fill out a form on a clipboard. This information is then transferred to a computer where a patient […]

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Oversharing: You’re Ignoring Your Child’s Privacy When You Post Online

Take it down, please.  The above is a typical text message parents send to kids when they discover their child has posted something questionable online. More and more, however, it’s kids who are sending this text to parents who habitually post about them online. Tipping Point Sadly — and often unknowingly — parents have become some […]

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Federal Cybersecurity Workforce Is Key To Our National Security

The Federal government has long struggled to close the cybersecurity workforce gap. The problem has continued to get worse as the number of threats against our networks, critical infrastructure, intellectual property, and the millions of IoT devices we use in our homes, offices and on our infrastructure increase. Without a robust cyber workforce, federal agencies […]

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What You Can Do to Reduce Your E-Waste This World Environment Day

Our love of technology and often biological need for new devices has created one of the biggest environmental issues of our time – e-waste. Today is World Environment Day – a great opportunity to ensure we are doing all we can to minimise landfill and protect our precious environment. Over the last 12 months, BYO […]

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Is Trouble Brewing for Owners of Smart Coffee Makers and Kettles?

There’s an undeniable appeal to a smart coffee maker that knows when you wake up so you’re never left without a freshly brewed pot. Or a smart tea kettle that heats water to the perfect temperature for brewing your favorite varietal. But does the convenience of automation put your personal data up for grabs? Could smart coffee […]

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Mr. Coffee with WeMo: Double Roast

McAfee Advanced Threat Research recently released a blog detailing a vulnerability in the Mr. Coffee Coffee Maker with WeMo. Please refer to the earlier blog to catch up with the processes and techniques I used to investigate and ultimately compromise this smart coffee maker. While researching the device, there was always one attack vector that […]

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How McAfee’s Mentorship Program Helped Me Shine in My Career Journey

By: Anshu, Software Engineer “The mind is not a vessel that needs filling, but wood that needs igniting.”—Mestrius Plutarchus A mentor isn’t someone who answers your questions, but someone who helps you ask the right ones. After joining the McAfee WISE mentorship program as a mentee, I understood the essence of these words. WISE is […]

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Attention Graphic Designers: It’s Time to Secure Your Canva Credentials

Online graphic design tools are extremely useful when it comes to creating resumes, social media graphics, invitations, and other designs and documents. Unfortunately, these platforms aren’t immune to malicious online activity. Canva, a popular Australian web design service, was recently breached by a malicious hacker, resulting in 139 million user records compromised. So, how was […]

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Are Your Kids Part of the TikTok App Craze? Here’s What Parents Need to Know

What phone app has over 150 million active users and more than 14 million uploads every day? You might guess Facebook, Instagram, or Snapchat, but you’d be wrong. Meet TikTok — a video app kids are flocking to that is tons of fun but also carries risk. What Is It? TikTok is a free social […]

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The GDPR – One Year Later

A couple of weeks ago, one famous lawyer blogged about an issue frequently discussed these days: the GDPR, one year later. “The sky has not fallen. The Internet has not stopped working. The multi-million-euro fines have not happened (yet). It was always going to be this way. A year has gone by since the General […]

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McAfee Playing an Ever Growing Role in Tackling Disinformation and Ensuring Election Security

As Europe heads to the polls this weekend (May 23-26) to Members of the European Parliament (“MEPs”) representing the 28 EU Member States, the threat of disinformation campaigns aimed at voters looms large in the minds of politicians. Malicious players have every reason to try to undermine trust in established politicians, and push voters towards the political […]

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What Will You Do If You Find That Your Kids Are Sharing Their Troubles and Pains Online?

“Am I fat?” “I am so depressed. Please help! I have been scoring less, my parents don’t understand me… my brilliant siblings treat me with disdain… my girlfriend has broken up with me….” “Thanks! That’s why I feel a connect with you- you really get me (no one else does!) ….” “I am closing my […]

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Don’t Let Airbnb Scams Stop Your Summer Travel Plans

With summertime just around the corner, many people are planning vacations to enjoy some much-needed R&R or quality time with family and friends. Airbnb offers users a great alternative to a traditional hotel experience when they are looking to book their summer getaways. However, it appears that cybercriminals have used the popularity of the platform […]

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Cryptocurrency Laundering Service, BestMixer.io, Taken Down by Law Enforcement

A much overlooked but essential part in financially motivated (cyber)crime is making sure that the origins of criminal funds are obfuscated or made to appear legitimate, a process known as money laundering. ’Cleaning’ money in this way allows the criminal to spend their loot with less chance of being caught. In the physical world, for […]

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RDP Stands for “Really DO Patch!” – Understanding the Wormable RDP Vulnerability CVE-2019-0708

During Microsoft’s May Patch Tuesday cycle, a security advisory was released for a vulnerability in the Remote Desktop Protocol (RDP). What was unique in this particular patch cycle was that Microsoft produced a fix for Windows XP and several other operating systems, which have not been supported for security updates in years. So why the […]

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Endpoint’s Relevance in the World of Cloud

Businesses everywhere are looking to cloud solutions to help expedite processes and improve their data storage strategy. All anyone is talking about these days is the cloud, seemingly dwindling the conversation around individual devices and their security. However, many don’t realize these endpoint devices act as gateways to the cloud, which makes their security more […]

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How to Get the Best Layered and Integrated Endpoint Protection

Security teams have historically been challenged by the choice of separate next-gen endpoint security technologies or a more integrated solution with a unified management console that can automate key capabilities. At this point it’s not really a choice at all – the threat landscape requires you to have both. The best layered and integrated defenses […]

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Breaches and Bugs: How Secure are Your Family’s Favorite Apps?

app safety

Is your family feeling more vulnerable online lately? If so, you aren’t alone. The recent WhatsApp bug and social media breaches recently have app users thinking twice about security. Hackers behind the recent WhatsApp malware attack, it’s reported, could record conversations, steal private messages, grab photos and location data, and turn on a device’s camera […]

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How MVISION Mobile can combat the WhatsApp Buffer Overflow Vulnerability

A new WhatsApp vulnerability has attracted the attention of the press and security professionals around the world. We wanted to provide some information and a quick summary. This post will cover vulnerability analysis and how McAfee MVISION Mobile can help. Background On May 13th, Facebook announced a vulnerability associated with all of its WhatsApp products. […]

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Cloud 101: Navigating the Top 5 Cloud Management Challenges

Cloud management is a critical topic that organizations are looking at to simplify operations, increase IT efficiency, and reduce costs. Although cloud adoption has risen in the past few years, some organizations aren’t seeing the results they’d envisioned. That’s why we’re sharing a few of the top cloud management challenges enterprises need to be cautious […]

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Privacy Awareness Week 2019 – Are You In The Dark About Your Online Privacy?

If you haven’t given your online privacy much attention lately then things need to change. In our era of weekly data breaches, the ‘I’ve got nothing to hide’ excuse no longer cuts it. In my opinion, ensuring your privacy is protected online is probably more important than protecting your home and car! A sloppy approach […]

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I am an AI Neophyte

I am an Artificial Intelligence (AI) neophyte. I’m not a data scientist or a computer scientist or even a mathematician. But I am fascinated by AI’s possibilities, enamored with its promise and at times terrified of its potential consequences. I have the good fortune to work in the company of amazing data scientists that seek […]

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On Mother’s Day, Show Your Love for Your Mom by Introducing Her to Helpful Apps

A mobile chat with my mother usually goes off like this: “Hello! Can you hear me! I am very busy so can’t talk much! I have a question.” “Umm OK but is your speaker on? Can you please speak a little softly?” “Yes, yes, OK… I know how to operate smartphones. Still smarter than a […]

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Saving Summer: 5 Strategies to Help Reign In Family Screen Time Over Break

summer screen time

It’s the most wonderful time of the year — for teachers and lifeguards. For everyone else (parents) we have a little prep work to do to make sure the summer doesn’t lull our kids into digital comas. Most of us have learned that given zero limits, kids will play video games, watch YouTube, send snaps, […]

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Celebrating Mother’s Day: How McAfee Supports Expecting & Working Mothers

Mother. It’s one of the best, hardest, most rewarding, challenging and unpredictable jobs a woman can have. As we approach Mother’s Day in the U.S, I’m reminded of the immense happiness motherhood brings me. I’m also reminded of my own mother. As a child, I distinctly remember watching her getting ready for work. I remember […]

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Avoid a Security Endgame: Learn About the Latest “Avengers” Scam

Marvel Studio’s $2.2 billion box-office hit “Avengers: Endgame” has quickly risen to the second-highest grossing film of all time in its first two weekends. Not surprisingly, cybercriminals have wasted no time in capitalizing on the movie’s success by luring victims with free digital downloads of the film. How? By tempting users with security shortcuts so […]

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#Verified — Worth the Risk?

In the social media world, a little blue checkmark next to a username is a sought-after status symbol. Celebrities, global brands, famous pets, and public figures alike have verified Instagram accounts, indicating to fans that the account they are following is “verified” as the real deal. With an established social presence and verified status, these […]

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What is Phishing? Find Out with Gary Davis on the Latest Episode of Tech Nation

Gary Davis is now a regular contributor on the Tech Nation podcast!  In this episode, Gary Davis educates that phishing is more than just an innocent-looking email in your inbox and shares tips to avoid getting hooked. Moira Gunn:   00:00   I’m Moira Gunn, you’re listening to Tech Nation. Moira Gunn:   00:06   I was surprised to […]

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Confused about Cybersecurity Platforms? We Can Help.

“Cybersecurity platform” continues to be an industry buzzword. Vendors talk about it at industry events, and many analysts. But can every vendor claim to offer a platform and also be credible? More importantly, how does that help your business? The security industry has evolved by responding to emerging threats with new, shiny tools, resulting in […]

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It’s World Password Day – the Perfect Excuse to give your Passwords an Overhaul!

How much of your personal data is stored online? Well, if you are anything like the ‘average Jo’ – the answer is a lot! In 2019, the vast majority of us bank and shop online, have official documentation stored online, have all sorts of personal information stored in our emails and let’s not forget about […]

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Why Data Security Is Important

The Increasing Regulatory Focus on Privacy The ongoing trend of data breaches and the increasing privacy risks associated with social media continue to be a national and international concern. These issues have prompted regulators to seriously explore the need for new and stronger regulations to protect consumer privacy. Some of the regulatory solutions focus on […]

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Wi-Fi Woes: Android Hotspot App Leaves 2 Million Passwords Exposed

Logging onto a free Wi-Fi network can be tempting, especially when you’re out running errands or waiting to catch a flight at the airport. But this could have serious cybersecurity consequences. One popular Android app, which allowed anyone to search for nearby Wi-Fi networks, was recently left exposed, leaving a database containing over 2 million network passwords unprotected. […]

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Remote Patient Monitoring and Self-Responsibility

At HIMSS next week, I’ll be doing 5 presentations about the future of healthcare IT, focusing on patient directed data exchange, internet of things, and telemedicine.     Remote patient monitoring,  which combines all three, will be increasingly important.

Remote patient monitoring can take numerous forms,  and the evidence supporting these tools is mixed. Here’s another excerpt from our new book—The Transformative Power of Mobile Medicine—co-authored by Paul Cerrato that dives into the issues.  For those interested in reading the entire book, the publisher is offering a deep discount until March 31, 2019; coupon code: HIMSS2019.

Many thought leaders are convinced that remote patient monitoring improves patient care, but surveys suggest that health-care professionals are still not convinced. An analysis from the New England Journal of Medicine Catalyst Insights Council asked respondents to rate various patient engagement initiatives. “Remotely monitoring using wireless devices/wearable” was listed as the least effective way to engage patients while having physicians, nurses, or other clinicians spend more time with patients was listed as the most effective tactic. [1] There is also uncertainty about the benefits of remote patient monitoring in the scientific literature. Of course, remote patient monitoring can take so many different forms that it’s impossible to make a blanket statement about its effectiveness. But a randomized controlled trial (RCT) that included more than 1400 patients (median age 73 years) who had been hospitalized for heart failure generated less than encouraging results. Michael Ong, MD, from the University of California, Los Angeles, and his colleagues divided the group into an intervention arm, which received health coaching phone calls along with the collection of vital signs that included blood pressure, heart rates, symptoms, and weight with the help of electronic devices, and a control arm that received the usual care [2]. Ong et al. couldn’t find any significant difference in hospital readmission rates 180 days after discharge for any cause: 50.8% were readmitted despite having all the extra attention and access to all the high-tech monitoring devices versus 49.2% in the usual care arm. Similarly, the investigators detected no difference in 30-day readmission or 180-day mortality. The experimental group did, however, report better quality of life at 180 days.

 On the other hand, Essentia Health, a Minnesota-based system that includes 16 hospitals and 68 clinics, has been using home telemonitoring with a body weight scale to keep track of CHF patients. Patients weigh themselves every morning and answer a few basic questions about their symptoms. Their responses are transmitted via telephone line to the computers that triage the incoming data and alert clinicians to those in need of additional attention. Essentia has been able to reduce 30-day readmission rates to less than 2% with the program. The average readmission rate for CHF patients
is 25%. [3-4]

Detecting statistically and clinical significant benefits for remote patient monitoring is complicated. Unfortunately, Americans are used to being passive recipients of health care. When they see their physician, they expect to receive a pill or have a procedure performed. The only demand on their time and attention is taking the pill or undergoing the operation. Asking patients to take on a more active role in their care, including weighing themselves daily, taking blood pressure readings, and so on, requires a stronger sense of self-responsibility and better cognitive skills. It also requires a deep, long-term commitment from the health-care care organization launching the program. Providers cannot expect to “patch” a remote patient monitoring system into the mix without a great deal of planning and commitment from physician leaders and clinicians in the trenches. Tracy Walsh, a senior consultant with the Advisory Board, sums up the issue succinctly: providers need to “track program metrics that closely map to the organization’s broader strategic objectives.” [5]. Walsh provides a detailed graphic to help providers choose wisely. It addresses three basic questions regarding remote patient monitoring:

·     Is it technically feasible?

·     Is it clinically relevant?

·     Is it cost-effective?

References

1.     Volpp KG, Mohta NS. Patient engagement survey: improved engagement leads to better outcomes, but better tools are needed. NEJM Catal May 12, 2016;. Available from: https://catalyst. nejm.org/patient-engagement-report-improved-engagement-leads-better-outcomes-better-toolsneeded/.

2.     Ong MK, Romano PS, Edgington S, et al. Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the Better Effectiveness After Transition_Heart Failure (BEAT-HF) randomized clinical trial. JAMA Intern Med. 2016;176:310-18.

3.     Siwicki B. Essentia Health slashes readmissions with population health initiative, telehealth. Healthcare IT News. March 15, 2016.

4.     Agency for Healthcare Research and Quality. Heart failure disease management improves outcomes and reduces costs. ,https://innovations.ahrq.gov/profiles/heart-failure-disease-management-improvesoutcomes-and-reduces-costs?id5275.

5.     Walsh T. Studies are conflicted about remote patient monitoring—here’s what we think. Advisory Board March 31, 2016;. Available from: https://www.advisory.com/research/market-innovationcenter/
the-growth-channel/2016/03/remote-patient-monitoring-roi.

What’s Next for Healthcare?

Today I had the honor of keynoting at a major announcement from Apple, Aetna and CVS/Caremark.   I’d summarize the message as “Digital Health has arrived and is now mainstream, fully embraced by the major stakeholders in the healthcare ecosystem.”

Here’s the upshot.

The history of healthcare and payment has been risk pool based and focused on paying for sickness.

The future belongs to wellness, personalization, and a team-based approach to keeping you healthy in your home. 

The announcement of Aetna Attain, a collaboration of Aetna, CVS/Caremark, and Apple, is based on a few key ideas:

1.  Personalization is essential
Asking everyone to walk 10,000 steps a day is unrealistic.   Some should walk 5000 and some should walk 20,000.    Performance goals should be set based on past performance, current health state, and patients like you.

2.  Privacy is foundational
Managing an ecosystem of apps, interfaces, and cloud services requires that privacy is designed in from the ground up.   Everything around Attain is based on opt-in, patient controlled privacy preferences, de-identification, continuous authentication (how are you holding your phone now), and aggregation of information.

3.  Machine learning based on patients like you is empowering
Randomized controlled trials are great but impossible to personalize.  Ideally, the past data from millions of patients like you will inform your wellness strategies for the future.

4.  Incentives/alerts are important to motivate wellness
We’re all busy people.   There are many tasks competing for our attention.   If we’re reminded at just the right time, maybe we’ll be more likely to follow through on positive behaviors.   If we’re given an incentive payment (or even compelling, avoiding a penalty) for achieving our goals, we’re more likely to focus.

5.   A combination of historical medical experience plus telemetry is powerful
Raw data in the absence of context is rarely helpful.   A few years ago I had a debate with a major industry executive who argued all healthare data is “atomic” i.e. all we need to know is systolic blood pressure then we can act.  I countered that we need to know history, current symptoms, medications, how the blood pressure was taken, and patient care preferences before action can be taken.   The Attain approach is to combine all these factors before suggesting wellness behaviors.

As I said in my keynote today, I’m very optimistic about 2019.   Attain is a great example of  emerging technology convergence – internet of things, cloud, machine learning, telecare, and security coming together.    The industry will learn a great deal from the Attain project about patient generated healthcare data, patient data stewardship and alignment of incentives for wellness.

I’m glad to be part of the exploration.

Embracing ChromeOS (and the cloud mindset required)

2019 will bring many changes.   After more than 20 years as a Chief Information Officer, I will pivot to lead innovation as part of the senior leadership team for the newly merged Beth Israel Lahey Health on March 1, 2019.
   
Here’s the Boston Business Journal article about it.

My innovation role will focus on 5 areas:

A front door/liaison to government/industry/academia for digital health collaboration at Beth Israel Lahey Health

Exploring new technologies, especially those arising from outside healthcare, to assess their role in provider/patient/payer workflow

Mentoring startups and internal faculty seeking to create new products/services especially in the areas of machine learning, mobile, telecare, internet of things and blockchain

Lecturing/writing to broadly disseminate lessons learned about innovation

Hosting of international visiting groups from around the world which want to learn about our innovation efforts.

In many ways, this next step combines the best of my youthful experiences researching and writing in the early 1980’s Silicon Valley with my 30 years of experience as an IT leader and professor.    I look forward to it.

In the early 1980’s while writing for Infoworld, I had the opportunity to personally evaluate emerging products – the IBM PC, Compaq’s portable, Wordstar, Microsoft compilers, and various dial up modem services.  Nearly 40 years after evaluating the first PCs, I’m now evaluating Chromebooks and ChromeOS as the next frontier in personal computing.   Here’s the experience thus far.

Think of ChromeOS as not just an operating system replacement for Windows or MacOS/ioS but an entirely new approach to computing.   It’s essentially a cloud viewer, consuming data and services available on the internet combined with limited offline replication of data just in case the internet is not available.    What does that mean?  Instead of using a local file system to store my documents, media, and data, I’m using Google Drive.   If my device is lost, stolen or damaged, there is nothing to hack on the device.    My Chrome applications are all web services with nothing running on the local Chromebook – Gmail, Gsuite, and Outlook Web Access (or Office 365).   

Why is this a useful concept?    A few months ago, I was in Tel Aviv and I damaged my computer.  There was no way to replace/repair it easily.   If I had been using a Chromebook, I could buy any $200-300 Chromebook and immediately have access to all my data and services.

The Pixelbook supports Android apps in addition to ChromeOS, so I can run local software with local data if I chose.   I’ve added a few such apps such as Nest (cameras, smart home controls), Gmail offline (local replication of email), and Weatherlink (to control my weather station), but I really don’t need them.   The combination of my phone for apps and a Chromebook for cloud hosted services works extremely well.

Are there downsides?   Absolutely.

Cloud/web native apps may not be as sophisticated or usable as locally installed apps.   Moving from local storage to cloud storage requires some planning and adaption.    I installed sync software on my previous computer and synced all my files into Google drive so cloud migration was one step.    I set up offline files so that every document I edit in the cloud is replicated into offline storage on my Chromebook for easy access when I’m on an airplane without wifi.     I previously managed photos and media on devices but now I manage them in the cloud.    All of this is change and requires getting used to.

For my use case – productivity applications, email, media management – a Chromebook works perfectly well.    I imagine there may be tasks/high intensity computing  use cases for which the cloud application and file system approach may not be optimal.   But for me, it works.

Truly, about the only thing I would like to see improved is that the Beth Israel Deaconess version of Outlook Web Access (2013) is not as full featured as Gmail or Office 365.    Once we upgrade or migrate, then the final piece of my cloud-based computing environment will fall into place.

I know that I may be edgy by suggesting that thin client, cloud-centric computing is the future, but from a security, cost, and maintainability perspective, it certainly seems like the right direction to me.

Exploring the Connected Medical Home

Over the past few weeks, I’ve been exploring the combination of internet of things, artificial intelligence, and ambient listening with a focus on how these technologies might improve care management, patient/family navigation of the health system, and wellness.

Google, Apple, and Amazon all have ecosystems that include the functionality I’m writing about.  Purely because I’m spending January investigating the Android/ChromeOS environment, my first exploration has been with Google products.    I’ll explore Apple next.

Here’s my test bed:

Unity Farm Sanctuary heating and cooling is controlled by Nest Thermostats.

The animal areas are streamed from Nest Cameras.

In the living room, I’ve installed a Google Home Hub, a Chromecast Generation 3, and Chromecast audio (now discontinued).

I’m currently carrying a Google Pixel 3 phone running Android Pie.   My personal computing platform this month is a Google Pixelbook.

What does this infrastructure enable me to do?

Here’s a sample dialog (Google product responses are in italics)

Ok Google, what is the temperature in the living room?

The farm living room is at 66 degrees.

Ok Google, increase the living room temperature to 68 degrees

The farm living room temperature has been increased to 68 degrees.

Ok Google, show the cows on TV

Showing the Sanctuary Cows on the Farm Living Room TV

Ok Google, play music on the speakers

Playing selections from Google music on the farm kitchen speakers

Ok Google, pause.

Music paused.

Ok Google, call Mom

Calling Mom

This internet of things, artificial intelligence, and ambient listening example illustrates the many possibilities for any internet connected home.    As 5G cell phone technology is deployed in 2020, gigabit internet will exist over the air throughout the country – no wires/fiber needed.   The potential is only limited by our imagination.

What exactly is the potential?   Google Home enables the definition of routines – a kind of macro that links commands together, including “if this, then that” kinds of controls.

For example

Ok Google, Good Morning

Good Morning John

It’s 22 degrees outside and today will be dry with a high of 32 degrees.

Your commute to work today will take 47 minutes because traffic is heavy

Increasing the temperature of the kitchen and decreasing the temperature of the bedroom

Playing morning music

Ok Google, Good Night

Turning off the lights

Activating the security system

Reducing the temperature of the kitchen and increasing the temperature of the bedroom

Sleep well

All of this has worked so well, that it makes me believe the future of computing is not limited to phones and apps, but increasingly a voice driven integrated ecosystem that requires very little technical expertise to use.

The artificial intelligence components can be startling.

Ok Google, play NCIS on TV

NCIS is available on CBS All Access and The CW

CBS All Access

Playing NCIS from CBS All Access on the Farm Living Room TV.  I will play from CBS All Access next time you ask for NCIS.

This required identifying that NCIS is a television program, offered by certain vendors, each with a different way to play it.   Notice also that I was vague about which TV to use, but Google Home figured it out.

Fast forward to healthcare. As we think about the integration of wearables and other in home wellness devices, this technology can integrate devices, routines, and voice commands to measure activities of daily living, suggest healthy behaviors, evaluate compliance with care plans, and communicate with care teams.

Today, only those with technological literacy and dexterity can perform these functions with a collection of apps, but it takes diligence, planning, and a steep learning curve.

Assembling all the connected home functions described above was done by me, in a few minutes, by unboxing devices and doing minimal setup – a one time only event.

As we move from fee for service to value-based purchasing, reimbursement reform will align incentives for wellness in the home rather than the treatment of sickness.  I predict that healthcare delivery organizations will restructure themselves for success  by shifting work from building more hospital beds to empowering patients outside of the hospital.  This will require training clinicians in  telemedicine  (let’s call the new medical specialty “virtualists”), home support people (both visiting nurses and connected home technicians), and care managers who ensure all services are coordinated to maximize quality while reducing total medical expense.

To me, this tech works so well, and is so affordable (compared to treating sickness), that the future of the connected medical home looks very bright.

Dispatch from India

I spent last week in Bihar, an area of Northern India near Nepal.  The best way to describe the journey is in pictures.

Our small team visited villages along the Ganges to the east of Patna, tracing the path of patients from seeking care to diagnosis to treatment to compliance to wellness.   We met with patients, providers, field officers (think of them as care managers), chemists (pharmacists), and labs.    Here’s what we experienced:

The villages had hand pumped water supplies, electricity and 4G cellular connections.  Cows and goats were a part of many households.

A unique telemedicine program from World Health Partners (WHP) provided access to experts, connecting each village to trained clinicians in urban areas.    We participated in such a consultation.

We visited patients in their homes to hear their stories.  All of us were touched by Pooja, a 25 year old new mother who spent 70,000 rupees (about $1000) on unnecessary medical care due to a misdiagnosis.   She had to sell her land and her cow to pay for healthcare.   We’ve started a go fund me to help rebuild her life.

We reviewed medical records and imaging studies, which in India are maintained by patients and families.  In this photo, I’m reviewing the records of a TB patient who is feeling better after treatment, but appears to have a negative initial chest X-ray.

We visited a local lab which offered a menu of diagnostic tests ranging in price from $.70 to $14.00. Diagnostics included GeneExpert TB testing and 3D doppler ultrasound.   All lab data is manually recorded on paper and carried by the patient.

Local chemists make available a range of medications at very low cost.

Medical record keeping is done via a brief note which is the property of the patient.  Prescriptions are often abbreviated in a way that can be hard to decipher but a local chemist can understand.   Registry data is entered for tuberculosis and is one of the few electronic workflows, completed on low cost android phones by provider support staff.

I came away with a better understanding of the cultural, political, and clinical workflow in the state of Bihar.   Next steps will be designing the digital health services which are most likely to serve the stakeholders, now that we have experience with their requirements and constraints.  We’ll do everything possible to leverage the remarkable national cloud hosted services available in India including identity management via Aadhaar, payments via UPI  and the rest of the “India Stack”.

As I wrote last week, the next 30 years of my life will be dedicated to purposeful causes that I hope
will make a difference.    India and China, which comprise more than 1/3 of the humans on this planet,  seem like the right focus for 2019.

Choosing Effective, Sticky Health Apps (Part 2)

In a blog post last week, I shared an excerpt from the new book that Paul Cerrato and I just completed, The Transformative Power of Mobile Medicine.  Here is a second excerpt from Chapter 3,  “Exploring the Strengths and Weaknesses of Mobile Health Apps.”

Even patients who are fully engaged in their own care still need access to medical apps they can trust. The IQVIA Institute for Human Data Science has performed a detailed analysis of the clinical evidence supporting mobile health apps, rating their maturity and relative quality. Its rating scale places a single observational study near the bottom of the scale, progressing upwards through multiple observational studies, a single randomized controlled trial, multiple RCTs, a single meta-analysis, and several meta-analyses. Using this methodology, it organized mobile apps into several categories. In the category called “Potential disappointments—more study required” are apps for exercise, pain management, dermatology, autism, schizophrenia, multiple sclerosis, and autism.  In the category called “Candidates for [clinical] Adoption” were mobile apps for weight management, asthma, COPD, congestive heart failure, stroke, arthritis, cancer, PTSD, insomnia, smoking cessation, stress management, cardiac rehabilitation, and hypertension. The most important category listed in the IQVIA analysis, which it considered candidates for inclusion in clinical guidelines, were diabetes, depression, and anxiety.

IQVIA has also generated of list of “Top rated apps” for 2017, taking into account their top clinical rating and the fact that they are free and publicly available.  Top rated apps in the free list includes Runkeeper by FitnessKeeper, Inc, Headspace, for stress management, Kwit, for smoking cessation, My Spiritual Toolkit, an AA 12 step program, mySugr, for diabetes management, and SmartBP for hypertension. In the top clinical rating list are Omada, for diabetes prevention, BlusStar Diabetes by WellDoc, Kardia by AliveCor, for atrial fibrillation and dysrhythmias, MoovCare for cancer patients, AiCure for medication management, and Walgreens medication refill app.

The UK’s National Institute for Health and Care Excellence (NICE), has also made real progress in evaluating mobile health apps. One of its missions is to provide guidelines for the use of health technologies within the NHS. NICE reviews data on drugs, medical devices, diagnostic techniques, surgical procedures, and health promotion activities, basing its recommendations on clinical evidence that demonstrates these treatments and activities are effectives, and on economic evidence that shows they are cost effective. [1]

The Institute has evaluated numerous mHealth services, with very detailed reviews of each service or mobile app.  Among the apps that have been studied: GDm-Health, which is intended for women with gestational diabetes, AliveCor Health Monitor and AliveECG app for monitoring cardiac function, Sleepio, for adults with sleeping problems, VitalPAC, for assessing vital signs in hospital patients, LATITUDE NXT Patient Management System, which allows clinicians to monitor cardiac devices at home, and numerous others. [2]

To illustrate the depth and thoroughness of the NICE reviews, consider its analysis of GDm-Health. The review explains the app’s purpose, which is to download data from a patient’s blood glucose meter and send it to a secure website where it can be monitored by clinicians. The web site also lets clinicians send text messages to patients to help them manage their condition. But NICE does not stop there. It also evaluates the app’s clinical effectiveness, user benefits, and the impact that its use would have on costs and resources. It then puts the mobile app into the context of NICE’s guideline for gestational diabetes, explains several of the app’s features in detail, and goes into an extensive discussion of the evidence supporting the app, including summaries of each of the clinical trials that support its use, the key outcomes, and its strengths and limitations.  

1. NICE. Technology appraisal guidance. https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-technology-appraisal-guidance     Accessed Feb 6, 2018.
2. NICE. Mobile health technology search results. https://www.nice.org.uk/search?q=mobile+health Accessed Feb 6, 2018.

The Meaning of Life (as a CIO)

As I approach 60 and reflect on over 40 years in the healthcare IT industry I sometimes feel that I’ve transitioned from a rogue upstart to the leader of the status quo – always about to be disrupted. I’m no longer a trouble maker, I calm the troubled healthcare technology waters.   If I’m not careful, that could mean I’ll become a rate limiting step to radical change since I’ve been shaped by a lifetime of experience that started with punch cards, paper tape, and Fortran.

The themes I’ll write about twice a week in 2019 will be about exploring new technology around the world and in a Boston-based lab, the Healthcare Technology Exploration Center at Beth Israel Deaconess Healthcare System, which I lead.    We’ll evaluate new products, ideas, and workflows.   We’ll pilot innovations and fail fast (if needed) so that we can rapidly converge on the right tools for the business requirements we’re given.

In our first quarter we’ll describe an evaluation of the Google ecosystem and potential healthcare implications for Android, Chrome OS  and sensor devices such as

Google Pixel 3 phone
Pixelbook
Google Home Hub
Google Chromecast 3rd Generation
Google Mini-home
Google Chromecast Audio
Nest Thermostat
Nest Outdoor Camera

We’ll review internet of things devices including the Withings suite of watches, blood pressure cuffs, sleep monitors, thermometers, and scales.

We’ll evaluate telemedicine devices and services that bring cloud hosted, machine learning driven decision support to patients and providers.

And of course, we’ll take a deep dive into everything Apple is doing in digital health space.

Why am I starting a new lab as I approach 60?   Simple – the meaning of life  (in my view) is about finding a purpose that serves the world selflessly, while surrounding yourself with people who give you a sense of belonging, enabling you to pursue your passion, and ultimately composing the ongoing narrative of your life.

To me, improving wellness with digital health around the world excites me every day

For example,  today I’m in Patna, India at the corner of Nepal, Bhutan, and India evaluating the potential for cloud services, apps, and devices to be used in resource constrained settlings for the management of tuberculosis.

There is no better way to solve a problem than to immerse yourself in the lives of the people you are trying to help, which is what I’m doing this week in homes, clinics, pharmacies, and hospitals.

However, a sense of purpose needs a group of like minded people who give you a sense of belonging. People you can talk to – sharing your successes/failures, and asking for feedback on your ideas.   Throughout my life I’ve been lucky enough to surround myself with people smarter than me, who are a constant source inspiration and energy.    At the moment my sense of belonging comes from extraordinary collaborators in international governments, academia, industry, foundations, and non-governmental organizations (NGOs).       I have a special respect for people in their 20 and 30’s who have far fewer biases and battle scars than me.

Although my passions have changed over the years, there is a common theme.  I’ve always worked at the edges of disciplines.   I’m a physician but my academic work has been at the intersection of medicine and digital health.  In my youth I was the first student at Stanford to have a computer in my dorm room (I built it).   I was the first young journalist to review a portable (25  pound) computer from a new company called Compaq.     I was the first person in Wellesley, Massachusetts to get broadband.   All of my experiences have been at the margins of the possible before the ideas were even considered reasonable.

And I’ll continue to tell my story via the evolving narrative of my life.    In an upcoming post, I’ll explain that my biography should start with the sentence  “He was the Forrest Gump of healthcare information technology” purely because by random chance I’ve been present at every major health related IT innovation of my generation.    And over the next 30 years (I’m vegan, so I should last that long), I’m hoping to be present for the amazing things my friends, students and collaborators do to change the world.

So my meaning of life is about making a difference in digital health around the globe, surrounded by inspirational people, investigating new ideas at the edges of the possible, while creating a story filled with impactful events.    

And that’s what I’ll write about over the next year.

Choosing Effective, Sticky Health Apps

In a recent blog post, I talked about the new book that Paul Cerrato and I just completed, The Transformative Power of Mobile Medicine.  In that post, we shared the Preface to the book in the hope that it might pique readers’ interest in mobile health.  What follows is an excerpt from Chapter 3, “Exploring the Strengths and Weaknesses of Mobile Health Apps.” 
Choosing Effective, Sticky Health Apps
Even healthcare providers who see the need for innovative mobile apps still face numerous obstacles. Given the human tendency to seek the path of least resistance, identifying the most effective, “stickiest” mobile apps becomes a real challenge. In Realizing the Promise of Precision Medicine, we discussed the need to individualize medical care and the importance of improving patient engagement. When choosing mobile health apps to meet patients’ needs, it is critical to keep both goals in mind. Each patient is at a different stage in their journey, with some lacking basic knowledge about their disorder and others almost as well informed as their providers. With that in mind, the prescription of health apps should be geared to an individual’s level of patient engagement. 
Mobile apps can be divided into several broad categories based on the level of engagement that each patient has reached. Patients will likely lose interest in a health app if it is not consistent with their level of engagement. [1] Among the categories that can meet patients’ needs are apps that:
‘Provide educational information
Alert patients to take some specific action
Track their health or medical data
Present patients with data that they have put into their mobile device
Offer advice based on the data that patients input into their device
Allow patients to send information to their family or healthcare provider
Provide social network support
Reward patients for changing their behavior.’ [1]
An activated, fully engaged patient will likely know most of the basics that would be provided in a mobile app that only offers educational information and will lose interest in the digital tool quickly. Conversely, a patient who is only modestly interested in managing a chronic condition may not benefit from a more in-depth app that tracks their medical data or physiological parameters. They must learn to “crawl before they walk.” 
The second category on the list, namely alerting patients to take some action, requires a closer look as well. No doubt many patients have benefited from mobile apps that remind them to take their medication on time or to make an appointment for their periodic mammogram or colonoscopy. Forgetfulness is a normal human failing and these apps can address that. But to be realistic, most non-adherence is not driven by poor memory. It’s driven by far more complex and entrenched motives, and the reason many patients fail to heed their provider’s advice is because it is just not that important to them, or because in their minds the risks outweigh the benefits, or because they can’t afford the prescribed intervention, or because they didn’t fully understand the advice offered or….  The list is long.
Addressing the first issue, Ira Wilson, an authority on patient adherence, points out that ‘we don’t forget to pick up our kids from day care or to make dinner or anything else that’s really important.’ [2] With that reality in mind, it’s not surprising that reminder apps that send patients alerts frequently fall short. This once again emphasizes the point we have made elsewhere in this book: Mobile tools can only supplement medical care, not replace it. And for clinicians to motivate such uncooperative patients will require time, a precious commodity in today’s healthcare environment.
Time is required to ask patients about why they don’t want to follow a prescribed course of action. Time is required to query patients about possible obstacles to adherence: “Can you afford this medication?”  “Does it cause unbearable GI reactions?” “Do you have a way to get to your next appointment or would it mean losing a day’s pay and possibly termination?”  “Do you think your hypertension requires medication even though it’s not causing you any pain or discomfort?”  We obviously can’t solve all our patients’ problems, but knowing what’s behind their noncompliance is the first step toward resolving it.   
Ira Wilson takes this type of deeper probing to heart when he works with patients:
Wilson doesn’t push reluctant patients to take their medications. During a visit with a man with poorly controlled hypertension, for example, Wilson began by asking, “What does hypertension mean to you?” The man replied, “I’m kind of a hyper guy. And sometimes I get tense.” He explained that he takes his medications only when he feels both hyper and tense. In such situations, I [the author of a New England Journal of Medicine editorial] would probably reply, “That’s not how it works,” but Wilson gently asks, “May I share a different perspective?” And patients usually say, “Of course, that’s why I’m here.” 
People like Wilson don’t need a digital reminder to have these conversations or to abandon the “doctor knows best” dynamic. For those of us who struggle, the most effective adherence booster may be giving doctors and patients the time to explore the beliefs and attributions informing medication behaviors. These conversations can’t happen in a 15-minute visit. [2]

Singh K, Drounin K, Newmark LP et al. Many Mobile Health Apps Target High-Need, High-Cost Populations, But Gaps Remain. Health Affairs. 2016; 35:2310-2318. 
Rosenbaum L. Swallowing a spy—The potential uses of digital adherence monitoring. N Engl J Med. 2018;378:101-103.

Embracing Android

Happy New Year!   I’ll be posting blog entries twice a week in 2019, describing my experiences in the healthcare IT innovation economy and international digital health.

Throughout my history in the industry, I’ve tested many emerging technologies and tried to predict future winners.   Here’s a CIO magazine article from 2007 in which I replaced my computing platforms each month to rigorously test Windows vs. Linux vs. OSX

In the late 2000’s, I felt that Microsoft had lost its agility and focused on adding features that few people wanted at the expense of usability.   I switched to Apple products because the software felt more utilitarian, secure and stable.

Now, I’m asking if Android and Chrome OS has the balance of features and usability that best meet my requirements for 2019.

I’ve moved to my phone to a Google Pixel 3 to help answer that question.

Thus far, my experience has been remarkable – a good mixture of speed, stability and usability.   I think of it as a toolbox that doesn’t prompt me to adopt functions that I don’t want.  

One of the best features is a simple consolidated notifications display that enables me to scroll down from the top of the screen and see every change that has occurred since I last picked up the phone – email, texts, app messages, reminders, and calls.

The gestures are intuitive.    The browser is Chrome (works everywhere with everything) and the email client is the highly usable and stable Gmail client

I’ve been so impressed with the functionality of my Android phone that I decided to move my computing environment to Chrome OS and Android as well.   My Google Pixelbook arrives on Friday and I’ll travel with it in India next week.

I’m writing this using Gsuite.    My data is stored on Google Drive.  I’m making my purchases with Google Pay.

All of this will be an interesting experiment, but thus far, it seems to me that the future of healthcare IT looks belongs to cloud hosted applications/services accessed from thin browser-based and mobile clients.   Android/Chrome OS might very well be those thin clients.

I’ll report on my experiences as they evolve.

The Power of Mobile Health

2018 was a very busy year, requiring extensive international travel—I racked up more than 400,000 miles this fall.   But now that my schedule is a bit more manageable, I plan to start posting again to “Life as a Healthcare CIO”. In addition to my travels to China, Japan, Australia and a long list of other countries, I managed to find the time to work with my esteemed co-author Paul Cerrato on our third book, The Transformative Power of Mobile Medicine. We wanted to share the Preface with readers and have included it below, along with a link to Elsevier’s web site for those interested in reading the entire book.

Cynicism, Optimism, and Transformation

Words are powerful tools, weapons even. They can persuade skeptics, overcome bigotry, injure colleagues, disrupt the status quo, ruin reputations, shatter misconceptions, deceive the uninformed, endear us to loved ones, comfort the grief stricken. The list is almost endless. The three words that are most relevant to our discussion of mobile medicine—cynicism, optimism, and transformation—are no less potent.

Many stakeholders in healthcare have become cynical about the value of information technology in improving patient care, some of which is justified. Clinicians have valid concerns about the ability of the current crop of electronic health record systems to deliver cost effective care. Others doubt whether patient-facing mobile apps can effectively engage patients in their own care or lighten the load of practitioners already burdened with too many responsibilities. And many grouse about the seemingly endless list of IT-dependent government regulations that slow them down.
But for many, cynicism has become more than just a reaction to legitimate concerns. It’s become a national religion, coloring their view of emerging innovations and potentially transformative technologies. John and I are not members of that sect. While we are both optimists by nature, our enthusiasm for mobile technology is not naivete. Call it evidence-driven optimism. Our combined 60 plus years of work on the clinical and IT sides of medicine have convinced us of the value of clinician-facing and patient-facing mobile apps, telemedicine, remote sensors, and numerous other digital tools.

The comedian Stephen Colbert, in one of his more serious moments, once said: “Cynicism masquerades as wisdom, but it is the farthest thing from it. Because cynics don’t learn anything. Because cynicism is a self-imposed blindness, a rejection of the world because we are afraid it will hurt us or disappoint us. Cynics always say no. But saying “yes” begins things. Saying “yes” is how things grow.”

Like Colbert, our goal in this book is to reject the cynic’s view of healthcare. We are interested in growth. And as our subtitle suggests, that growth entails leveraging emerging innovations, seizing opportunities, and overcoming obstacles to mHealth.

In our previous book, Realizing the Promise of Precision Medicine, we demonstrated that mobile medical apps have both “potential and kinetic energy,” i.e., there’s evidence to show that several mHealth initiatives will improve patient care in the near future, and several initiatives have shown mobile medicine is improving patients’ lives now. The Transformative Power of Mobile Medicine will take this theme into deeper waters, exploring the latest developments in mobile health, including the value of blockchain, the emerging growth of remote sensors in chronic patient care, the potential use of Amazon Alexa and Google Assistant as patient bedside assistants, machine learning, the latest mobile apps being developed in Beth Israel Deaconess Medical Center (BIDMC) and elsewhere, and much more. These innovations and opportunities, however, also need to be put into the context of clinical medicine as it is practiced today, which will pose challenges in terms of validation and implementation. With these concerns in mind, we address criticisms and skepticism in the medical community and take a critical look at the published literature on mobile apps in diabetes, heart disease, asthma, cancer, and other common disorders.

Equally important, we discuss the design process for creating new mobile medicine products, exploring successes and failures, the regulatory environment, and the importance of involving clinicians in the designed process at every stage.

mHealth initiatives are certainly no panacea, but they represent a new path for clinical medicine and for patient self-care that will have a profound impact for many decades. We hope our words will accomplish all the positive things words have the ability to accomplish, persuading skeptics, disrupting the status quo, shattering misconceptions, and demonstrating the power of evidence-driven optimism.

Paul Cerrato, MA
John Halamka, MD, MS

Embracing the New, New Thing

My life has been devoted to the pursuit of innovation – attempting to embrace new ideas and new technologies before the path ahead is completely clear.   Admittedly, I have not leveraged social media to the extent I should have.

For a decade, I’ve posted blogs and for many years wrote lengthy posts every day.  In recent months, as my writing has focused on books, articles, and the new Blockchain in Healthcare Today peer reviewed journal, I’ve written fewer blog posts.

In an age where the news cycle is 24 hours (or less), I’ve found that people appreciate more frequent, shorter communications, so I’ve turned to Facebook and Twitter to write daily updates, exploring ideas as they happen.

I intend to keep the blog and post at least monthly reviews of policy, technology, and current events.   I’ll also include relevant guest posts.

As the newly appointed International Healthcare Innovation Professor at Harvard (in addition to my CIO job), I’m traveling the world, learning every day from bold thinkers.   Today I’m in Qingdao, China meeting with Haier Corporation (bought GE appliances)  to brainstorm about the future of healthcare.  

I look forward to sharing new ideas with all my colleagues past, present and future via a more robust social media presence!

My Technology Christmas List for 2017

Although this week will be lighter because of the holidays,  the work never ends.   At the Sanctuary, I’m using our Terex skid steer and its attachments (consensus method from forums suggests the “blade” to create windrows then the snowblower attachment to move the windrows. Light snow – blade only). Although we did not receive more than a few inches of snow, we are getting early bitter cold, so snow will not be melting for the next 10 days.  It was a very white Christmas!

Here’s my technology Christmas list for 2017

The Sanctuary now uses outdoor Nest cameras so that we can remotely view the animals to better keep them safe.

To enhance reliability, I needed to install a mesh network first to boost the signal.

Now we can see what is happening if the Great Pyrenees bark at night, or if we hear Star the donkey braying.

May your 2018 be happy and healthy.

Another Dispatch from a Broken Healthcare System

I’m working on a series of “Dispatches from a Broken Healthcare System” based on my personal experience as a care navigator.   I’ve already written about a frustrating care management experience

Today’s blog is a guest post from Amy Stiner, a healthcare expert and single mom from the Pacific Northwest.    She reflects below on what should be a simple task – transferring records between institutions in the age of Meaningful Use.

“My name is Amy Stiner and my healthcare consulting career has taken my 6-year old son, my mother, and me progressively across the country.  Over the course of Grant’s sweet little life, he has been a patient at 8 nationally recognized academic health systems.  In a sentence, my son has a severe form of ADHD with an extremely severe feeding disorder without a clear etiology.  He is progressively starving to death.

We have experienced healthcare delivery in a variety of health systems in cities that are inclusive of Boston, St Louis, Chicago, Honolulu, and Seattle. Even exotic, Eau Claire, Wisconsin.  After leaving Boston in 2011, things have gotten messy with medical records and transfers of care.
Based on my experience,  the two biggest contributors to the delays in transitions of care across America have been:
1) Medical Record Requesting
2) Transfer of Care Handoff/Provider Referrals/Conversations

By far, the biggest offender is the medical records requesting process. You may be wondering – how is it possible that requesting medical records is creating such massive delays in care? The answer is not straightforward, but rather a sequence of events that delay initial appointment scheduling.  This exercise has become a series of hoops to jump through,  ultimately obtaining that ‘prized appointment’ with a specialist or sub-specialist.  I am a mother and clinician who is constantly pursuing the ‘gastroenterology and feeding clinic appointment merit badge’.

The Mission Should I Choose to Accept It

Every time I attempt to get him established with a new health system, I am more often met with a brick wall of obstruction at the entry point for care rather than a welcome mat.  The initial appointment conversations (90% of the time) go something like this:

“Before your son can be scheduled—we need to have a copy of (1) the medical records and (2.) referral/phone call person to person conversation from your former physician.”

Hearing that sentence alone is enough to make my voice raise a whole octave.  They know and I know that ‘patient first care’ is never a part of that sentence.  I have been in this industry long enough to know why they have made it my problem to chase information because providers can’t seem to obtain it efficiently either.  If my child’s condition worsens or if he is running out the prescription formula that he needs the health system doesn’t suffer but my son, my mother, and I do. Delays in patient care hurt the whole family.

A Convoluted Process of…Processes

Once again, I am being given my marching orders by the new patient in-take person. Go find all the records.  Go chase your referring physician for a physician to physician phone call.  “Don’t call us, we’ll call you when we get around to it after we receive everything and only if we remember to look for them and don’t lose your records first.”  Its like a Monty Python sketch. It would be funny if it wasn’t true.

I hang up the phone, fighting back swear words and tears.  I know that I don’t have the time during a work day, while in a different time zone, to chase these things.  That the evening, when I should be reading a bed-time story to my son or trying to get him to take in a few more life sustaining calories, I will instead be downloading 8 different multi-page medical request forms to my PC. Then I’ll remember that I don’t think I have enough ink in the printer for all the pages.  One academic health system (with Nobel Prizes in Economics) has three (3) pages of instructions on how to fill out the two (2) page request form.  It then follows those instructions up with all the different postal addresses that the form will need to be copied and mailed too.  Yes.  Postal mailing the same form in different envelopes to different locations for the same health system.  Ironically, we are all not realizing economies of scale in this process.

Each form makes me carefully select all the locations of patient care within the health system, where my son has been seen. Why can’t they just aggregate it based on his account number or something and magically pull it all together?  They all make me choose if I want notes, records, images, mental health, reproductive health, and more.  I always anxiously look for the “ALL RECORDS TICK BOX”—EVERYTHING!!!  I WANT EVERYTHING!!!  There isn’t a magical everything box, so I resentfully tick mark each individual little box for everything.

I hurriedly complete this information on 8 different multi-page forms for each health system and the instructions sound like a lecture from a teacher in high-school “If the information provided is incomplete records will not be sent.”  I really hate this process and I suddenly realize I don’t have enough postage stamps to mail the ones that need to be mailed.  I now make an unplanned trip to the post office. I am angry, and the printer is beeping as I walk out the door to get stamps.

The Options Aren’t Impressive and Not User Friendly

Along with all the above  I am asked to select the media by which the health systems will send and receive the information.  Disc? Paper? Images? Some simply tell me what the doctor is going to get.  That’s it.  The doctor doesn’t get a choice—the doctor is going to get paper or a disc and hopefully that provider can just deal with the paper or disc that is being sent. I can’t use the disc, my PC doesn’t have a disc drive. I pray the physician has one.

Receive a paper copy of the information myself? I must pay for it.  Lord only knows how many pages there are? Some health systems charge per page.  Why aren’t these items in the portals or sent in an electronic format?  It is 2017 and surely healthcare technology should be adopted to handle this seemingly simple task?

The Mystery Treasure Hunt Ensues

I have never seen the full records from any of the facilities that have cared for my son and have no idea what is already existing in each one from a prior provider. I assume they are a mess.  Each move, I have requested medical records from every single place just to be on the safe side (to get everything).  In theory there should multiple copies in the record from each past health system.  Based on recent experience, I imagine they haven’t received much because I had to do this whole thing twice, and only after that duplicated process did we receive one single copy from one institution in Chicago. Although we didn’t know initially if anything had really been received.

After my insistence, a kind-hearted network of health system leaders formed a medical record search party.  They looked for anything sent from 8 institutions with my son’s name on it.  “OH, WAIT!  WE FOUND ONE OF THEM!” cried the search party. The HIM department didn’t know what to do with the information—because they had no existing record to put it in. It was set aside until a record was started. (See how that worked?) We are delighted for the recovery and it calls for a celebration. I bought a bottle of wine and my mother was ecstatic on all fronts.

The Result

One year later, my son finally had his appointments after the initial step of the process was begun, the result of delayed records and missed phone calls between physicians with never ending phone tag.  The outcome of those appointments now has us planning a return to the East Coast.  His weight loss is worse than last August 2016, and his level of care involves more complexity in delivery. The silver lining in all of this, is that I have an amazing son and I am 100% committed to this marathon in a race against time for him and others.  There are other parents/care givers who are running the marathon with less time left than we have.  What will days, weeks, and months of delayed care  have cost all of us because of dangerous medical record request and referral processes we have in place?  My little guy and I are eternal optimists.  We believe that those of us in healthcare can and will do better.  Immediately. “

Dispatch From South Africa

My blog readers must think I’ve abandoned them over the past few weeks.   I apologize for the whirlwind of October and November.    With the BIDMC-Lahey merger planning and the new cloud hosted Meditech go lives of my day job, plus the usual Fall conference commitments, and my new work with the Gates Foundation, blogging has fallen behind.

The Gates Foundation has a bold plan for Africa – unifying the health records of the continent using biometrics, simple phone apps, and a highly resilient low bandwidth cloud that includes data integrity components based on blockchain.

Here’s the use case – patients with HIV are medicated and then monitored for viral suppression using Viral Load lab tests drawn 6 months after therapy begins.    This process requires accurate patient matching between clinic visits, which might occur at different locations and with different care providers.

In the US, exact matching of demographics works about 60% of the time.   Probabilistic models work about 80% of the time.    South Africa has a similar experience. The end result is that many lab tests are redundant and wasteful.    Measuring outcomes is challenging.    Closing the loop for followup may be impossible.   Biometrics can improve matching to 99%, improving quality, safety and efficiency.

South Africa has a “90/90/90” national strategy – 90% of HIV positive patients should know they are HIV positive.   90% of those should be on anti-retroviral medication.  90% of those should have documented viral suppression with viral load tests.

I’ve joined an amazing multi-disciplinary team that includes the Gates Foundation, biometric engineers, app developers, usability experts, cloud database/blockchain innovators, and security professionals.

Over the course of 5 days we met with government, academic, and industry leaders throughout South Africa to plan a 2018 pilot of a nationwide patient matching strategy.     We’ve  devised objective metrics for success that include improvements in patient and provider satisfaction as well as reductions in total medical expense.

I’ve written about the Perfect Storm for Innovation.   South Africa has all the ingredients – senior leadership of top government healthcare leaders, a guiding coalition of people to oversee the work, appropriate resources to do the work, and an urgency to innovate.    I’m hoping that the work in Africa will demonstrate how a nationwide patient matching strategy can work, serving as a model for the world, including the US which continues to struggle i.e. CHIME cancelled its patient matching challenge 

The South African people are amazingly kind and helpful.   The National Health Laboratory Service has a best in class repository of lab data for the entire country.  With Gates funding as a catalyst, I’m convinced we can make a substantial difference in 2018.

In addition to visiting clinics, labs, data centers, hospitals, and IT departments, I had the opportunity to visit an animal sanctuary near the border of Botswana.   It’s just like Unity Farm Sanctuary except that instead of pig belly rubs, I gave lion belly rubs.    An amazing experience.

Unity Farm and Unity Farm Sanctuary Update for November 2017

Starting next month, my daughter Lara will take charge of our instagram, Facebook, and Twitter feeds, providing daily updates about the Farm and Sanctuary.    As we approach winter 2017, we can officially declare that the farm and sanctuary are now fully built and we’re transitioning to daily operations.   We have over 250 animals at this point, all kept healthy, warm and fed every day.   Here’s a summary of the past month, as told in pictures.

From mid October to early November, the swamp maples, oaks, and poplar take on shades of crimson and bright yellow, turning Unity Lane into the kind road less traveled that Robert Frost wrote about.

Palmer the turkey surveys his empire as the leaves begin to fall.    11 more turkeys have arrived at the Sanctuary and they have designated Palmer as their alpha male.

The five mini-horses weigh about as much as a Great Pyrenees and have all adapted to their new homes.    Goldie, an 18 year old stallion, was recently gelded and he’ll soon join the others in the main mini-horse paddock

We’ve finished the cider making for 2017, having harvested 55 different types of apples from the Unity Farm orchard.     Our hard cider this year will be a combination of Golden Delicious (sweet), McIntosh (tart), and Macoun (aromatic)

As the temperatures drop below freezing, we’re working extra hard to keep every creature fed from the bounty of the fall harvest – apples, pumpkins, and lettuce from the hoop house

We’ve had our share of animal medical issues – an alpaca with a jaw abscess, a mini-horse with a food impaction, and chickens with eye infections.   All have been treated appropriately and thus far, they’re recovering.     Mocha, the dark brown alpaca is eating again after antibiotics and pain medication for her jaw.

My recent trip to Africa for the Gates Foundation included animal sanctuary visits – just like Unity Farm they have “horses” and guinea fowl.

And pigs with slightly bigger tusks than Tofu the potbelly pig

By Thanksgiving, every night will be below freezing on the farm.   The heated buckets are hung, the animal buildings are fortified against the elements, and the food stores are replenished.     Let it snow,  let it snow, let it snow.

Don’t Let Things Slip Away From You

Kathy has written this guest post, about the unexpected death of a friend.

“Please don’t let things slip away from you:
first steps,
first kiss,
first real vacation…
first time you know that something is not quite right in your body.

I discovered yesterday that someone about my age whom I have known for at least 15 years had passed away in September. I had seen her once during the summer.

I was told by her colleague that about a year and a half ago, she noticed leaking from one breast. Her coworkers persisted in asking about the situation and she then told them it was just an infection from a cat scratch. It is not clear she ever sought any medical care at that point.

Fast forward to this summer: she developed pneumonia and liver failure, consequently was hospitalized, and all the way to the end she did not acknowledge that the test results showed widespread metastatic breast cancer.

Speaking as a breast cancer patient past my 5 year mark post treatment, none of it was fun or easy, but I bless every day I am given to enjoy my life and family. I think I was so floored by the discovery that my acquaintance had died in a state (MA) where we have had mandatory health insurance for a long time. I have lost other friends to breast cancer, one dying after it infiltrated her brain, but she could never afford health care as a self-employed artist in the era before mandatory health insurance. I know she spent about two years convincing herself nothing was wrong too – until it was too late to do anything.

My father “toughed it out” as he lost weight and grew fatigued. By the time I realized how many pant sizes he had dropped, the neuroendocrine tumor on the head of his pancreas was untreatable. I daily feel robbed of his smile, I am only reassured knowing that he passed so quickly after diagnosis that he never had much time where he was incapacitated.

All this leads to express my hope that if you know something is not quite right in your body, face the risk of getting a diagnosis even when you don’t want to hear the news. Your family and friends want to know you for as long as they can. And cancer therapies and treatments are making amazing advances – while there is life there is hope.”

Building Unity Farm Sanctuary – September 2017

I’m on a flight to New Zealand as part of my international government service.  The 26 hour commute means that even with just two days of meetings in Auckland, I will be gone from the farm for 5 days.

I spent Saturday morning cleaning paddocks, emptying manure carts, packing hay bins, filling water troughs, and doing the final repairs/maintenance that will ensure the farm/sanctuary can thrive for a few days while I’m gone.

 What happens at the sanctuary over a typical week?

 Numerous volunteers spend time with animals, providing companionship, exercise and socialization

Horse experts bond with Amber, Milly, Grace, and Sweetie, showing them love, respect, and skill as they build enough trust to ride them.   Star our donkey has dedicated volunteers that cherish their time with her, and give her the attention she loves, and the exercise with walks that she needs. Donors bring us saddles, bridles, medicine, blankets, and food to keep the horses healthy.

Our friends and colleagues help us create safe living spaces for our animals.   Here’s what our equine rescue area looks like today with 8 stall spaces,  an acre of paddock supported with heat, power, light, water, and a medical treatment area.

Our agriculture volunteers are helping with apple picking, mushroom log inoculation and harvest.   We picked 40 pounds of Shiitake this week.   Our 36 different varieties of apples are approaching that perfect picking moment.  How do we know?  We measure the starch and sugar levels of each tree to decide when to pick.    Here’s a great article about the process.

 New babies are born every week.   Two proud guinea parents brought us a dozen new children which we’re caring for in our brooders.

Just before I left I completed the organic certification for 2017, which is  very similar to a Joint Commission visit.   The inspector reviewed our entire operation, our record keeping, and our policies.   In 2017, we should achieve organic certification for our fruits, vegetables, honey, mushrooms, and compost.

We’re getting very close to completing our Sanctuary building phase – the electrical, plumbing, heating, windows/doors, painting, well systems, irrigation, and gutters/downspouts and fireplaces have all been fixed/maintained.    The last project before winter is the generator – a 20kw Generac to ensure the animals have water, light and heat even if winter storms knock out power.

2017 has been an amazing time – a faster pace of change, projects, and activities than Kathy and I every thought possible.  As we transition into Fall, we can say with confidence that the 200+ animals at Unity Farm Sanctuary are healthy, supported, and loved.   That’s all we could ask for.

Now you know why Kathy and I can never travel together away from the sanctuary.   While I’m in New Zealand, she’s running the enterprise.   The good news is that we have traveled the world together from 1980 to 2010.   At this point, we’re completely comfortable dedicating our lives to our sanctuary work.

Thanks so much to our volunteers, Board of Directors, and community for making it happen.

We Can Improve Care Management

As a physician and CIO, I’m quick to spot inefficiencies in healthcare workflow.  More importantly, as the care navigator for my family, I have extensive firsthand experience with patient facing processes.

My wife’s cancer treatment, my father’s end of life care, and my own recent primary hypertension diagnosis taught me how we can do better.

Last week, when my wife received a rejection in coverage letter from Harvard Pilgrim/Caremark, it highlighted the imperative we have to improve care management workflow in the US.

Since completing her estrogen positive, progesterone positive, HER2 negative breast cancer treatment in 2012 (chemotherapy, surgery, radiation), she’s been maintained on depot lupron and tamoxifen to suppress estrogen.   After three years on a protocol of 22.5mg of lupron every 3 months, her insurer and pharmacy benefits manager decided that 11.25mg was an equally effective dose and sent her a letter telling her they would no longer cover 22.5mg dosing.

Here’s the actual letter she received.

Harvard Pilgrim writes:  “HPHC has not made arbitrary decisions on the Lupron dosage for breast cancer, nor with any other policies for that matter. Rather, HPHC has implemented an IV drug management program using the best peer review medical evidence and professional societies guidelines. In the case of oncology drugs, the program has adopted recommendation from the National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 27 leading cancer centers devoted to patient care, research, and education. In Boston, MGH and DF/BW are NCCN member institutions.”

Harvard Pilgrim/Caremark was very collaborative in discussing next steps, and I was eager to bring them into the conversation.  

There are 5 issues with the letter.

1.   Her oncologist was unaware that Harvard Pilgrim/Caremark had such a program.    HPHC included an article about the new program in their newsletter and sent email to those clinicians who were likely to be affected.   Although a good attempt, those communication modalities did not reach my wife’s oncologist.

2.   The rule is stated in a confusing way as “prescriptions for 3.75 mg”.  How does this relate to my wife’s 22.5mg treatment?  

Harvard Pilgrim writes: “Per National Comprehensive Cancer Network guidelines, Lupron 22.5mg is indicated for prostate cancer and not breast cancer. For breast cancer, the guidelines recommend 3.75mg monthly or 11.25mg every three months (a 50% reduction in Kathy’s dose). “

Kathy would have preferred something like ‘national guidelines recommend a 50% reduction in dose to achieve the same outcome with fewer side effects’.

3.    Although Kathy’s oncologist is aware of the NCCN guideline, he believes the evidence supporting the guideline is scant (a single paper from 1990), so based on his experience with hundreds of successful cancer patients, he prefers 22.5mg.

Kathy’s oncologist writes:  “I think the Dowsett paper—and Mitch is great and a colleague—is a very small 1990 study using 2 doses of lupron in women with metastatic breast cancer.   Not very compelling evidence, especially when translated to a different clinical setting.    That being said, no one knows for sure what dose is adequate and it probably isn’t the same for all women.  In a treat for cure setting, we would rather err on the side of more drug than may be needed in that individual (as it is quite safe) rather than fail to suppress and therefore diminish effectiveness of planned treatment.   The absence of menses is not evidence of ovarian suppression since about 20% of women with no periods still have ovarian function.”

Harvard Pilgrim writes:  “The NCCN guidelines support the 3.75mg IV monthly injections because the 22.5mg depots every three months’ injections do not reliably suppress estrogen in all women, which is the whole point of the treatment There are numerous examples of individual physicians who make assumptions based on their observations and individual experience. In many cases, however, those observations have not been confirmed by future clinical trials and may reflect unconscious bias on the part of the treating physician.  Kathy’s oncologist doesn’t appear to have published his observations in a peer review journalwith hundreds of patients using the off-label dose of Lupron 22.5mg every three months. In addition, if he feels strongly that the 22.5 mg is the preferred dose, he has a professional obligation to suggest modifications of the NCCN guidelines. We don’t know if he has made an attempt to modify the NCCN guidelines.”

I completely understand Harvard Pilgrim’s motivation to implement a guideline, and NCCN is what is available.    The central issue with the letter is not the guidelines themselves, but how the program was implemented before patient/provider educational and workflow concerns had been addressed.

4.   The patient is being asked to manage something they lack the expertise to do – bringing together payer medical management and provider caregivers to discuss a medication dose.    

Harvard Pilgrim’s writes: “There are many avenues for appeal and the patient is not being asked to manage the process. The contracted provider, who is credentialed by HPHC and who has signed a contract with HPHC, has a responsibility to manage the process by calling the plan or the delegated entity or both, whenever he/she disagree with the initial determination. In addition, the patient and provider can submit a formal appeal requesting an external specialist’s review of the case.  In a similar different case to Kathy’s, the external expert in the same specialty  (not chosen by the plan), agreed with the NCCN guidelines and HPHC. The match specialist is a board-certified oncologist working at an academic medical center in Pennsylvania.  Finally, if the denial is upheld on first level appeal, the patient and physician can appeal to the State. The process is fair and equitable and attempts to balance self-interest and autonomy with common interest and use of evidence-based medicine with the ultimate goal of managing limited resources and continuously increasing care cost in the New England market.”

I leave the readers to judge for themselves if the patient is being asked to manage a process.

Harvard Pilgrim writes: “There are many avenues of appeal if the physician does not agree and the physician has a professional responsibility  to act as the patient advocate, and to explain to the health plan medical director the rational for  supporting a treatment that is not recognized by any of the compendia (Micromedix, Facts and Comparison) and NCCN guidelines.”

5.   The decision was made without consulting Kathy’s clinical record or cancer treatment protocol.   I’ve recently co-authored a book about precision medicine which highlights the need to combine evidence, patient preference, clinical history, genomics, and the experience of other patients to select the right treatments.    We all should be working toward that future.  

Harvard Pilgrim writes: “While Dr. Halamka is correct that we do not have access to clinical records, in order to ensure that we have relevant information, we ask the treating physician to provide it to us so that we can utilize it in decision-making Participating physicians are asked  to fill out a form (designed by the State) and include information relevant to the case. In addition, physicians have the opportunity to call the health plan or the delegated entity and initiate a peer to peer discussion. During the peer to peer discussion, the patient physician has the opportunity to provide the clinical rationale as of why the plan should cover a treatment that deviates from FDA, or other professional guidelines.”

Again, I leave it to the readers to decide how a clinician is going to follow that workflow while having 12 minutes to see each patient, comply with Meaningful Use-imposed  EHR burdens, be empathic, make eye contact, and never commit malpractice.

Harvard Pilgrim writes:  “A physician should never abdicate his/her ethical obligation to support his/her patients in the entire process of care. Many practices delegate certain non-direct patient care functions to other members of the clinical team. However, the physician must always act as patient advocate. In this case, patient advocacy means picking up the phone and having  a discussion with a medical director at the Health Plan. . To their credit, many  physicians do call the plan and interact with the medical directors.”

Sometimes in the healthcare industry we implement changes before policy, technology, and culture are ready.   For example, healthcare regulations required encryption of mobile devices  before any laptop or phone operating system supported encryption.    Meaningful Use tried to accelerate interoperability before we had an electronic provider directory, a nationwide patient matching strategy, or a framework for consistent privacy policy among states.  Care management disconnected from clinical workflow has the same problem.

Here are three alternatives which would markedly improve the patient experience

1.   The actual Harvard Pilgrim/Caremark formulary is shown below from the e-prescribing function inside my wife’s EHR.    I did an eligibility check demonstrating that both Caremark and Medimpact pharmacy benefits mangers consider 22.5 mg a preferred level 1 medication for 3 month administration without any designation that there is a care management decision support rule to consider.   Given that Kathy is female and therefore unlikely to have prostate cancer, there is no reason to offer the 22.5mg option.  Imagine if during e-prescribing, the rule was displayed/enforced so that 22.5mg wasn’t considered preferred level 1, resulting in a patient/doctor conversation before the medication is ordered.

Harvard Pilgrim writes: “The PBM or Health plan formulary is not designed as a drug management tool. The preferred product designation in the formulary is a cost management tool. The formulary must list all the available dosages so that even an off-label dosage can be dispensed, like in Kathy’s case, as an exception to the medical policy after discussion with the patient physician. Clearly, there is an opportunity to further educate providers on the difference between utilization management and formularies.”

2.  As a country, we need to finalize the standards for pre-authorization with clinical attachments.    Harvard Pilgrim/Caremark could create a rule as part of the pre-authorization workflow.    Appropriate clinical documentation would be required before the pre-authorization is approved, again resulting in a patient/doctor conversation before the medication is ordered.   Alternatively, the emerging Fast Healthcare Interoperability Resources (FHIR) Clinical Decision Support Hooks specifications  will enable EHRs to query cloud hosted clinical rules and display precision medicine information to the provider at the point of care.

3.  The letter from Harvard Pilgrim/Caremark, could be revised as follows

‘Harvard Pilgrim, Caremark, and your care team work together to keep you healthy.  We’re constantly reviewing evidence about the best possible treatments.     Based on recent research, it appears you are receiving too high a dose of Depot Lupron, which could cause unwanted side effects.    We will contact  your doctor and have a discussion about the protocol you are on, taking into account your individual medical history, to collaboratively decide on the best dose for you.    We just wanted you to know that in case your prescription changes, it’s all because of new knowledge and experts working together.’

I applaud the intent of care management as a way to improve quality and reduce costs.   However, just as with Meaningful Use, I think the letter is a good example of trying to do too much too soon.

I’m not asking that Harvard Pilgrim and Caremark eliminate their care management program.   I am asking that they realize the deficiencies of launching a program before the education and workflow redesign efforts were mature, putting the patient in the middle of what should be a payer-provider conversation. The tools to implement that payer-provider conversation don’t yet exist, but soon will and HPHC/Caremark could start by modifying their formularies to offer preferred choices in existing e-prescribing workflows.

As John Kotter taught us in his change management work, we need to follow a process, beginning with a sense of urgency in order to make lasting change.     We know that the US must reduce total medical expense while maintaining quality and optimizing outcomes if we are to have a sustainable economic future.   Care management based on evidence is the right thing to do.    Now we need to work together so that payer systems, decision support rules, and EHRs have a closed loop workflow for all involved.     I’m happy to serve on the guiding coalition, along with my colleagues at HPHC, to make this happen.

Building Unity Farm Sanctuary – August 2017

I’ve put down the pitchfork and shovel, returning to the keyboard to update everyone about our Sanctuary progress.    Here’s what’s happened over the past few weeks.

As Kathy wrote on Facebook on July 25, Pippin, our 30 year old Welsh Pony passed away from cancer.   His last few months included daily play with three other ponies, walks in the woods, and generous servings of grain/treats.    He was the centerpiece of our horse work at the sanctuary and we miss him every day.   He’s buried on a hill covered with oaks overlooking the barnyard marked by a large flat stone.

The sanctuary volunteer program now includes over 20 people who feed, bathe, exercise, socialize and medicate all the inhabitants of the sanctuary.    We also have volunteers helping out with the agricultural duties – harvesting, planting, and weeding.    This amazing outpouring of support from the community enables Kathy and I to keep everything (well almost everything) on track.

The new paddocks are almost done and we’ve officially begun placing the half mile of fencing around the new run ins.     After Labor Day, we’ll have enough capacity to take on a small herd of mini-horses, pictured below.    Between the sanctuary and farm we’ll have 20 stalls and 10 paddocks.   With help from a local excavator, we’ve dug the trenches and laid the pipe/wire  so that each stall has heated buckets, lighting, and easy access to water.

Lunchbox Benson, a vietnamese pot belly pig, nipped one of our volunteers on her ankle.   We flushed the area to ensure it was clean enough to bandage and sent her for medical followup.    Lunchbox has never shown any unsociable behavior, so we’re concerned that one of his tusks may be growing into his palate, making him defensive.   We’re searching for a vet with experience in pig dentistry – not an easy task.

Over the next month, the pace of farm activities will continue at a fever pitch as we harvest the remaining summer fruits/vegetables, garlic, plant the fall/winter crops, and begin preparation for winter.    All our construction and improvement projects will wrap up in September.   As Kathy and I joke, when we’re 64 in 9 years, the daily heavy lifting  will need to slow down.   (And Kathy assures me that she’ll still need me and will still feed me)

We set the foundation for the Unity Farm sanctuary flagpole this morning – a 25 foot fiberglass single piece that is weather resistant and will not attract lightening.    Kathy has designed the sanctuary flag that we’ll fly.

As a place of peace and protection, the Sanctuary continues to be a haven for local wildlife.   Yesterday, a dozen wild turkeys visited Star the donkey.    Thus far, all the local animals – coyotes, foxes, fisher cats, raccoons, possums, skunks, hawks, turkeys and deer pass the through the sanctuary every day without a problem.    There must be something about the environment which encourages good behavior.

The carriage house refinishing project is now finished, complete with a coat of USDA approved epoxy on the floors.   We’ve moved all the honey processing equipment from the cider house to the carriage house so we can more easily keep the bees out and ensure complete cleanliness of the honey products (cider processing includes a lot of flying apple chunks).    Kathy’s 40 hives have been productive this year and we’ll process nearly 1000 pounds of honey.

We’ve just completed our 2017 organic certification, following all the rules and documenting our compliance with organic best practices.   The onsite unannounced inspection will happen soon.

The rainy summer has produced a bountiful Shiitake mushroom crop and we picked 40 pounds last week.    We’ve delivered fresh organic mushrooms, cucumbers, basil, eggs, and lettuce to Tilly and Salvy’s farmstand in Natick.

Hopefully this gives you a sense of everything that has consumed us nights and weekends, reducing my writing time.     I promise to do better in the Fall!

Unity Farm and Sanctuary Guest Post

Over the past few weeks I’ve been writing a few journal articles and finishing a book, so my blog posts have waned.    They will start again soon.   In the meantime, my mother is visiting and here is her guest post.

Dagmar Halamka’s farm notes from August 4,2017 and August 5, 2017.

The beauty here is infinite – wildflowers everywhere, bee colonies in colorful hives, gushing fountains in ponds with swimming ducks and geese and vast amounts of greenery because of the frequent rain.  60 acres of enchanted forest  that even “House and Garden” magazine could not duplicate surround the farm.  Roosters begin crowing about 4:30am. A very slow moving freight train provides a marvelous whistle several times a day as it moves through the countryside.

Today was Blueberry picking day at Unity Farm.  It’s hard work!  An hour and a half of picking rendered one bucket (I ate a “few”). I am renegotiating my contract!

Palmer, the turkey, followed us around all day – wherever we went. He extends his plumage often so we can admire how grand he is. When I returned with the blueberries, ALL the geese greeted me with extensive honks (males) and hinks (females). I think they believed I had food for them.

Then planting time arrived – I planted 45 lettuce seeds. Really easy since John had already provided the soil blocks.

We streamed “Lion” yesterday evening. I highly recommend it. A beautiful story with an
endearing plot theme.

We visited the new “age restricted” (over 55) condominiums at Abbey Road – just 500 yards from Unity Farm on the trails through the sanctuary. I was immediately surprised by the Revolutionary W War era cemetery in the front of the development.

Tuesday, the local Garden club will come to Unity Farm for a potluck. Kathy admitted they will
market living in Sherborn to me.

Who knew that a machine existed to wash eggs – with an alkaline egg wash solution? The next step is to brush each one with a toothbrush and finally float them in a sink of water to determine if they sink or not (don’t eat the ones that float). We washed 10 dozen eggs.

I decided to walk to the post office (and to treat myself to ice cream at the C and L Frosty).   I was sauntering back when a torrential rainstorm appeared, seemingly out of nowhere. Kathy drove down in the car and truly rescued me.

Dinner with John’s daughter was at a Japanese restaurant in Wellesley. They lived
there before moving to Sherborn. So it has sentimental memories for her. She loves her job at “Game Stop”- especially interacting with all the customers.

More tomorrow.

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