Monday, November 20, 2017

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.

Wednesday, October 25, 2017

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."

Saturday, September 16, 2017

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.



Tuesday, September 12, 2017

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.

Thursday, August 17, 2017

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!

Sunday, August 6, 2017

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.