The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.

The Good Boss

One of my assignments as a young captain was serving as the convoy commander for our combat engineer battalion. We were moving over 250 vehicles across the state of Colorado. Given the size and type of vehicles (Hummers, dump trucks, semi-tractors carrying bulldozers), we covered a good 15 miles of highway end to end.

I missed a turn and inadvertently split my convoy in two. Applying a few off-road techniques, I’d put the pieces back together within a couple of hours. But not before catching the attention of the battalion commander.

At our next stop, I steeled myself for one of the famous ass-chewings our commander was known for. We both stepped out of our Hummers. He looked at me and said, “Carry on, Marx!” He spun back around and climbed into his vehicle.

That was it. And you know what? For me, that’s all it took and he knew it. He purposefully chose a different form of discipline for that situation. Later, he told me that he could tell by the look on my face that I had learned the lesson and understood the gravity. He did not have to say anything more. And he didn’t.

Earlier this year, I posted the Bad Boss. It is always easier to point out the negative over the positive. So what is the Good Boss?

I don’t believe there is a magical checklist of Good Boss attributes. There are too many variables and permutations. Put simply, the Good Boss first and foremost does not follow a checklist. She understands every person is unique and should be treated as such. Just like my commander following my convoy fiasco.

I crowdsourced for input. Here is a compilation of attributes of a Good Boss. This is not research or academia or consultant or stats based on one person’s experience. It is not a checklist. These are ideas, and I imagine they reflect the thinking of your staff as well. Ponder the following and adopt as your situation dictates.

Ensures Appreciation and Value

• Thanks subordinates regularly
• Demonstrates gratitude in words and action
• Rewards success
• Personalizes awards and recognition
• Listens often
• Gives the subordinate glory for success

Mentoring

• Takes active interest in the subordinate’s career and guides growth in the job
• Teaches the subordinate how to best interact with customers
• Encourages professional development and provides educational opportunities
• Willing to learn from the subordinate
• Hopes one day the subordinate will step into his position
• Guides the subordinate to their ultimate goal, even if it means losing them

Fairness

• Never steals ideas from subordinates
• Always honest and ethical to the core
• Does not undermine anyone
• Possesses a strong work ethic
• Treats everyone without bias (race, religion, ethnicity, gender, age)

Performance

• Sets high but reasonable standards and removes non-performers
• Gets more out of subordinates than they can get from themselves
• Sustains the continuity of the organization by hiring only “A” players
• Provides insightful and regular feedback
• Elevates performance without the subordinate even noticing
• Provides appropriate tools and training for the job

Team

• Holds individuals accountable to performance standards so the team does not suffer
• Represents team and department with passion and confidence
• Makes the subordinate feel proud to be on the team
• Takes public responsibility for the action of the team when failures occur

Transparency

• Makes themselves transparent and vulnerable
• Admits errors and apologizes without excuse
• Gets to know subordinate as a person (family, hobbies)
• Is in tune with their emotions and not afraid to show it (smile, laugh, cry)
• Shares their wisdom in decision making and is open to other possibilities

Vision

• Encourages vision
• Articulates and lives the mission and values of the organization
• Tells the subordinate when to be practical and when to dream

Positive

• Remains positive when things don’t go as planned
• Always finds the good in bad situations

Individuality

• Does not micromanage and allows for creativity and self-expression
• Welcomes and supports innovation and creativity
• Recognizes individuals strengths and positions people accordingly
• Knows when to be the boss, friend, or mentor
• Knows when to lighten difficult moments

Style

• Leads by influence and not by position
• Jumps In the trenches as needed
• Walks the talk and shows flexibility
• Trusts, respects, and gives benefit of the doubt
• Possesses high emotional and social intelligence

Miscellaneous

• Promotes work-life balance
• Allows for downtime
• Able to charm Joint Commission surveyors!

Is this how your employees describe you? Which of these attributes will strengthen your leadership? Remember, one size does not fit all. Treat everyone in the style that works best for that individual and circumstance.

Be the boss! The good boss.

Ed Marx is a CIO currently working for a large integrated health system. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook and you can follow him via Twitter — user name marxists.

Quality Systems, Inc. announced this morning that it has acquired The Poseidon Group, an Atlanta-based emergency department information systems vendor. Quality Systems will integrate the Navigator PC and NavigatorWeb EDIS modules into its NextGen Inpatient Solutions small hospital product line.

NextGen Healthcare Inpatient Solutions EVP Steve Puckett was quoted as saying, “This acquisition provides our clients additional value by extending our hospital suite portfolio of advanced solutions to the Emergency Department. This product along with our surgical services suite will help support our rapid growth upward into the community hospital market.”

The acquisition closed May 1. Terms were not disclosed.

Top News

Accretive Health sends a detailed response to Senator Al Franken, who is investigating the company’s hospital collection practices. The company says its primary purpose is to help patients by making sure they use the benefits to which they are entitled, also adding that the company follows HFMA guidelines, including making it clear that services won’t be withheld for financial reasons. Accretive says it complies with all federal laws, including HIPAA, and that all but one of its missing laptops was encrypted and that one was because a now-fired employee messed up. The company also hires a boatload of influential guns-for-hire former politicians to polish its tarnished reputation: former HHS Secretaries Mike Leavitt and Donna Shalala, former Senate majority leaders Tom Daschle and Bill Frist, and former CMS administrator Mark McClellan. Newt Gingrich on Line 1?

Reader Comments

From MT Hammer: “Re: Transcend Services (now Nuance). Medical transcriptionists file a class action lawsuit against the company for labor law violations.” The 13 named transcriptionists claim that Transcend violated federal labor laws by paying them per line of text transcribed or edited but not for related activities such as looking up information, thereby dropping their compensation below the $7.25 federal minimum wage. I’m surprised that Transcend hired them as work-from-home employees instead of independent contractors, but maybe the company provides more direction than would be expected for a contractor.

From David Stock-Man: “Re: Quality Systems/NextGen. Anyone have thoughts on the company missing its numbers and shares getting crushed?” QSII announced preliminary Q4 results last Thursday, with expected revenue for the quarter of $107-111 million and EPS $0.24-0.27, blaming revenue recognition delays for missing expectations and issuing guidance down for the fiscal year. FY2013 guidance calls for revenue and earnings growth of up to 25%. Some folks on the stock message boards are crying foul, saying that pro traders were taking huge put positions in the shares right before the announcement, suggesting the possibility that word leaked out (without having any proof, of course.) Shares that were trading in the $45 range just a handful of weeks ago are down to $30. Above is a one-year graph of QSII (blue) and the Nasdaq (red). Shares have a long track record of steady growth, are now priced relatively cheaply, and the company’s margins are good, so if you’re feeling confident that this is just a bump in the road, you get to buy shares at a discount (and if you’re wrong, you get to lose even more money). All I know is that quite a few of the old-school EMR vendors seem to be failing to meet lofty expectations lately despite billions of taxpayer dollars being spent to help them sell product, so if not now, when?

HIStalk Announcements and Requests

Thanks very much to the 68 readers who donated to support the four young daughters of Epic analyst and long-time HIStalk reader Tim Dodson of Children’s Medical Center (TX), who passed away recently at 34. Including the three of us who matched $250 in contributions dollar for dollar, our total contribution was $5,495, which I’ve deposited to the fund set up by Tim’s wife Wendy for the girls, flagging it with a note saying it came from Tim’s fellow HIStalk readers. I covered the credit card fees, so every dollar you donated went directly to support the children. Those of us who chipped in know that it could have been us who died young and unexpectedly, leaving a family deprived of not only their loved one, but of their primary breadwinner as well. You did good.

Acquisitions, Funding, Business, and Stock

The Trizetto Group announces that its subsidiary Gateway EDI has acquired NHXS, a provider of contract compliance and point-of-service adjudication workflow automation. Gateway will incorporate NHXS’s capabilities into its EDI and RCM offerings.

Wolters Kluwer sells its prescription data business to PE firm Symphony Technology Group.

Simplee, which offers free online medical expense management tools for consumers, raises $6 million in a Series A funding round.

Sales

Unity Health System (NY) selects Phytel’s Atmosphere platform as part of its infrastructure for population health management.

Cape Cod Healthcare (MA) chooses Courion Suite for user access management for its Siemens Soarian system, scheduled for a December go-live.

Stewart Webster Hospital (GA), a 25-bed critical access hospital, selects the ONE EHR from RazorInsights.

The State of Arizona contracts with Mosaica Partners for consulting help in updating strategic and operations plans for the state’s HIE.

Orange Coast Memorial Medical Center (CA) selects PerfectServe’s clinical communication platform.

Hartford Hospital (CT) will deploy OTTR’s transplant system, including the recently announced OTTRvad module for ventricular assist device patients.

Norton Sound Health Corporation (AK) will deploy ambulatory and inpatient solutions from NextGen.

Chesapeake Regional Medical Center (VA) contracts with ICA Informatics to develop an HIE for its integrated delivery network.

Boston Medical Center (MA) signs a five-year license agreement with Streamline Health for use of its business intelligence and analytics solutions in 19 physician group practices, while Bronx-Lebanon Hospital Center (NY) extends its licensing agreement with Streamline Health for five years.

North Texas Accountable Healthcare Partnership (TX) selects Orion Health’s HIE solution to connect its 12,000 physicians.

Advocate Health Care (IL) selects Merge Healthcare’s cardiac imaging and informatics solution. Merge also announces that 12 radiology and orthopaedic practices have selected its EHR products.

Aetna selects Kony Solutions’ KonyOne Platform for its mobile health app.

People

The Massachusetts eHealth Institute names Laurance Stuntz (NaviNet, CSC Healthcare) as director.

e-MDs hires former CO-REC director Robyn Leone as director of public policy and government initiatives.

M*Modal brings on Kathryn Twiddy (Quintiles, Misys) as chief legal officer.

Blair Butterfield (GE Healthcare IT) joins VitalHealth Software as president of its North American division.

Announcements and Implementations

Rockford Memorial Hospital (IL) goes live next spring on the health system’s $40 million Epic system. Rockford’s physician group has been live since last year.

SoutheastHEALTH and Missouri Delta Medical Center join forces to build and manage a $3.5 million networking and data storage center for their organizations and other medical providers. Both hospitals will also install a $12 million Siemens Soarian system over the next year.

Austin Diagnostic Clinic (TX) goes lives on PatientKeeper Charge Capture for its 120 physicians.

Aetna Pharmacy Management offers its members new services based on their prescription claims data: (a) switching to once-per-day meds when appropriate; (b) recommending trying a less expensive single component of a combination drug; (c) flagging prescription that have been taken longer than recommended; (d) sending prescribers a letter for daily doses that exceed that listed in product labeling; and (e) identifying cases where a new prescription may indicate that a previous one caused side effects.

Medical billing and financial management vendor Fi-Med Management says it will expand its services and add 145 new jobs in the Milwaukee area. It says its new software can help hospitals identify over- and under-charging and avoid audits.

Other

Allscripts will train and hire 40 City College of Chicago graduates, whose salaries will be paid by the City of Chicago for their first six months.

Cerner customer The Hospital de Denia achieves HIMSS Analytics Europe Stage 7, the first Spanish hospital and the second in Europe to do so.

A Northwestern Memorial Hospital (IL) employee is charged with identity theft after a police search of her home, triggered by her use of several credit cards to pay her water bill, uncovers the credit card numbers, birth dates, and Social Security numbers of more than 50 patients.

Last weekend I had the chance to snuggle with a relative’s new baby, which reminded me of this recent article. Laptop magazine compiled a list of 15 current technologies that newborns will never see, including wired home Internet, Windowed operating systems, hard drives, the mouse, desktop computers, and fax machines. If I had written the article, I would have put an asterisk by a few of them (desktops, fax machines) and added, “Not applicable to healthcare because providers are resistant to change.”

Sponsor Updates

• Surgical Information Systems recognizes five hospital systems with 2012 SIS Perioperative Leadership Awards, among them Holy Spirit Hospital (PA – above.)
• Certify Data Systems ranks as a tier one enterprise HIE vendor in the Chilmark 2012 HIE Market Report.
• CynergisTek expands its portfolio of offerings to include the HIPAA Surveyor Solution Series and the HIPAA Audit Readiness Solution Portfolio.
• AHA Solutions and GetWellNetwork host a Webinar featuring Texas Children’s Hospital and its interactive patient care RFP process.
• PatientKeeper awards Ashe Memorial Hospital (NC) its customer innovation award.
• EHRConsultant’s AIMSConsultant division provides advice on choosing the right anesthesia information management system.
• Informatica releases its Informatica 9.5 platform, designed to maximize customers’ return on big data.
• BridgeHead Software will sponsor The Big Event social gathering at the 2012 MUSE International Conference May 29-June 1.
• Computerworld honors Lehigh Valley Network (PA) with its 2012 Laureate award and NASCAR Teamwork award for its innovative use of DigitalShare, T-System’s ED patient documentation system that’s based on Shareable Ink technology.
• Barrington Orthopedic Specialists (IL) selects NextGen’s EHR, PM, portal, and other solutions for its 15-physician practice.
• College Park Family Care Center (KS) selects eClinicalWorks EHR for its 91 providers.
• Emerson Hospital (MA) integrates Access Intelligent Forms Suite with its Meditech Magic system.
• Kareo upgrades its billing system clients to a new release, which includes enhanced claim scrubbing capabilities.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Mobile.

We’re constantly giving you the scoop on the latest in orthopedic devices from our clinical and design perspective, but have you ever wondered about the steps that go into manufacturing these devices? There’s a lot of work in the process that turns an idea into an actual physical product, and often times it’s something we don’t think about.

During our recent trip to Northeast Indiana, we had the opportunity to visit a number of manufacturing sites and learn the high-tech processes and technology that go into producing orthopedic implants and instruments. Here’s how it works!

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Scientists at the Stanford University School of Medicine are developing a new type of retinal prosthesis which aims to simplify the complex surgery associated with existing, bulkier implants. The prosthetic comprises a pair of goggles and an implanted retinal sensor made up of an array of light-sensitive photodiodes.

The goggles incorporate a miniature camera, a pocket computer for processing the camera data, and an LCD screen embedded into the goggles for displaying the data. The LCD screen beams images using laser pulses of near-infrared light to a photovoltaic ultra thin silicon chip implanted beneath the retina. The chip, in turn, translates the infra-red pulses to neural pulses in the retina which can be processed as images in the brain. The key selling point for the new implant is the elimination of wires and cables and the relative simplicity of implantation.

Read More

A community of physicians who are actively involved with our video sharing site EchoJournal now has a collaborative blog where they’re discussing the latest echocardiography videos, clinical concepts and ideas. EchoBlog can be accessed from the EchoJournal website, or directly by going to EchoBlog.com.

If you are a cardiologist, anesthesiologist, radiologist, medical student, or just a person interested in cardiac ultrasounds, EchoJournal is where you can develop your knowledge and consult with others. To learn and discuss, you can watch new cardiac videos that are added almost every day, or you can browse through our video archives. To store or share, you can upload your own clips. The site has a growing membership base, and solid traffic stats. EchoJournal is curated by David E. Winchester, MD, a cardiologist at the University of Florida.

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We need beds. Discharge every patient you can. Most hospital-based physician will be familiar with this refrain. The problem is that it can lead to premature discharges of some patients, particularly post-op ones who may require closer monitoring and sophisticated nursing care. Revenue-driven surgery and poor planning result in some surgical patients being discharged too early concludes a pair of logistical studies conducted by researchers at the University of Maryland (see: Revenue-driven surgery drives patients home too early). Below is an excerpt from the article:

The studies show a correlation between readmission rates and how full the hospital was at the time of discharge, suggesting that patients went home before they were healthy enough. The researchers recommend better planning and other logistical solutions to avoid these problems ....“Discharge decisions are made with bed-capacity constraints in mind,” [said one of the study authors]. “Patient traffic jams present hospitals and medical teams with major, practical concerns, but they can find better answers than sending the patient home at the earliest possible moment,”[he added]. [The studies] found that patients discharged when the hospital was busiest were 50 percent more likely to return for treatment within three days....Surgeons and hospitals are incentive-driven to perform as many surgical procedures as feasible....“The hospital has to maintain revenue levels to meet its financial obligations. Surgeons are working to save lives and earn a livelihood. It’s what they do....“If the hospital says ‘sorry there are no beds available,’ there’s a lot of tension and pressure from both sides to keep things moving.” These problems are much more likely at large hospitals, which tend to provide more advanced, specialized surgeries not accessible at smaller, community institutions,the researchers say. Patients often have to travel a great distance for the procedures, so hospital delays become expensive for both them and the care providers. The study findings cover surgical discharge data from fiscal year 2007 covering more than 7,800 surgery patients who collectively spent 35,500 nights at the facility....Also, he suggests that hospitals increase the flexibility of where patients go post-surgery. Allowing them to be moved to units with empty beds, for example, could also lessen premature discharges.

All of this makes great sense to me. Now comes the interesting part. How are patients and their relatives supposed to convince a surgeon not to discharge a patient prematurely in the face of pressure from "upstairs". The latter often comes from hospital physician executives. The best argument, echoing the discussion in the excerpt above, is that the patient is not ready to go home and stands a good chance of being readmitted. This is an argument that will resonate with a surgeon if it is likely. A good surgeon, in fact, will have an understanding of which patients will do best at home and which should remain in the hospital for a longer stay. A patient's family should stand their ground and appeal a perceived premature discharge if the facts are on their side. Here's an excerpt from an article relating to premature hospital discharge (see: New Medicare Rules Protect Against Premature Hospital Discharge):

As a result of litigation initiated in 2003, hospitalized Medicare patients will now be better protected against being forced out of a hospital before they can be safely cared for at home or in a nursing home. The new regulations require that patients be given notice of their discharge rights on admission (although it can occur up to two days later) and again at least four hours before discharge. If patients or their families believe the discharge will be premature and not in a patient's best interest, they are entitled to an expedited review of the discharge decision. If they request an expedited review, the patient can remain in the hospital without charge at least until noon of the day following an independent agency's review. The independent review agency is called a Quality Improvement Organization (QIO), and the patient must get in touch with its staff by phone or in writing before the close of business on the day the hospital plans to send the patient home. The QIO demands that the hospital give the patient a detailed, written explanation of her medical condition and the basis for the proposed discharge. 

The need to develop an Accountable Care Organization (ACO) is one of the leading priorities of most hospital executives but there continues to be ambiguity about what an ACO is and what it is designed to accomplish (see: Hospital Executives Search for the Formula for an Accountable Care Organization; The End of Health Insurance Companies by 2020?). A recent article in The Atlantic discusses emerging healthcare models and then provides more details about ACOs (see: The 5 Mega-Trends That Are Changing the Face of Health Care). Below is an excerpt from the article about emerging models with ACOs being one of them. Read the whole article if you have time.

As the sweeping transformation in health care takes hold, several models appear to be taking shape. Each has its strengths and weaknesses and each presents opportunities and risks, but the following three deserve serious analysis and represent different points on the risk spectrum:

• Bundled payments model: calculates total historical payments for the various components of a bundle and then discounts or at least holds constant that amount, placing the responsibility for cost and quality control in the hands of the collective providers.
• Accountable Care Organization (ACO) model: seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.
• Capitation model: sends a fixed per-patient prepayment of premium dollars to a provider in return for medical services....

ACOs. For their part, ACOs are hardly proven, but in theory they should achieve results. The overarching idea is to get patients who aren't being treated in a coordinated manner into a system that can deliver care more effectively. The upsides to ACOs are:

• Physicians and other professionals have an opportunity to reap financial benefits of efficiency driven by quality.
• Hospitals that get involved can partially make up for declining volumes associated with higher quality and efficiency.
• Patients currently accessing services in a disjointed manner are likely to have a better overall health care experience in a coordinated system.
• Quality is likely to be enhanced because of coordination and aligned incentives.
• Providers will likely increase collaboration. Existing risk-bearing organizations can increase "membership," and many have already developed at least a portion of the infrastructure and have experience managing risk....

The ACO model, if more broadly accepted, could have a major impact on hospitals, especially because the overall goals here are to reduce unnecessary services and provide better overall health care, which would mean less traditional business for them. A prime issue is that costs--for labor, devices, supplies, equipment, and construction--aren't addressed. And the Affordable Care Act exacerbates this situation by creating additional taxes, such as those levied on device manufacturers and payers, that will be passed through to purchasers.

My general impression is that most hospital executives and, in fact, most healthcare professionals like nurses and physicians, don't have any idea about how to reduce unnecessary services. In fact, most of this group might have a hard time even defining unnecessary services. This is because most were trained and have practiced in an era of plenty where greater delivery of services was praised and elimination of services was criticized. Part of the dilemma lies in the fact that all services industries are highly dependent on labor costs (and new technology in the case of healthcare). Both sets of costs are difficult to ratchet down. In my opinion, part of the solution to the reduction of unnecessary services is engaging patients to take more ownership for their own health. Clearly, most of them need some advice about how to achieve this goal. Healthcare consumer education will thus be one of the major goals. Much of this will be accomplished via the web and social media but we have a long way to go to learn how to do it from both the hospital and consumer perspectives.

A new subdiscipline within oncology is getting increased attention -- survivorship (see: Cancer Survivorship, an Emerging Subdiscipline in Oncology; Cancer Survivorship and the Role of PCPs in Continuing Care of Cancer Patients). As cancer increasingly comes to be viewed as a chronic disease, more attention is being paid to the long-term medical problems of cancer survivors such as the drug damage to normal organs and also new cancers secondary to cancer therapy. Here's an account of second primary malignancy risk due to Revlimid (see: Cancer drug Revlimid (lenalidomide) raises secondary cancer risk). Below is an excerpt from the report:

The U.S. Food and Drug Administration (FDA) is informing the public of an increased risk of second primary malignancies (new types of cancer) in patients with newly-diagnosed multiple myeloma who received Revlimid (lenalidomide). Clinical trials conducted after Revlimid was approved showed that newly-diagnosed patients treated with Revlimid had an increased risk of developing second primary malignancies compared to similar patients who received a placebo. Specifically, these trials showed there was an increased risk of developing acute myelogenous leukemia, myelodysplastic syndromes, and Hodgkin lymphoma. 

Revlimid is used to treat newly-diagnosed multiple myeloma so its target is, obviously, plasma cells and their precursor cells. It's probably no surprise, therefore, that other myelopoietic and lymphopoietic cell lines could be affected by this drug. All of these cells have a high turnover rate in the bone marrow and lymph nodes. Here's an excerpt from the summary of a scientific article published in Sweden to give you some idea of the scope and scale of second primary neoplasms among patients with haematolymphoproliferative malignancies (see: Second primary neoplasms among 53 159 haematolymphoproliferative malignancy patients in Sweden, 1958–1996: a search for common mechanisms):

The Swedish Family-Cancer Database was used to analyse site-specific risk of second primary malignancies following 53,159 haematolymphoproliferative disorders (HLPD) diagnosed between 1958 and 1996....Among 18 960 patients with non-Hodgkin’s lymphoma (NHL), there was over a 3-fold significant increase in cancer of the tongue, small intestine, nose, kidney and nervous system, squamous cell carcinoma (SCC) of the skin, NHL, Hodgkin’s disease (HD) and lymphoid and myeloid leukaemia. Among 5353 patients with HD, there was over a 4-fold significant increase in cancer of the salivary glands, nasopharynx and thyroid, NHL and myeloid leukaemia, and over a 1.6-fold increase in cancer of the stomach, colon, lung, breast, skin (melanoma and SCC), nervous system and soft tissues and lymphoid leukaemia. Among 28 846 patients with myeloma and leukaemia, there was a significant increase in cancer of the skin, nervous system and non-thyroid endocrine glands and all HLPD except for myeloma.

There are at least three explanations for second primary neoplasms among patients with haemato-lymphoproliferative disorders: a genetic predisposition to later malignancies, lifestyle issues, and the lingering effects of treatment for the first  neoplasm. What is certain, however, is that surveillance for secondary neoplasms among these patients needs to be in high-gear. My own view is that such surveillance is best accomplished in specialized cancer centers but I think that many such centers may view their mission as emphasizing treatment over surveillance. However, this attitude is now being modified with greater emphasis on cancer survivorship. This is a welcome change.

The government might as well argue that, since handicapped people can crawl on all fours or ask for help from strangers, there's no need to make buildings wheelchair accessible, the court said.

• "Compassionate Conservatism" Rings Hollow with Bush Regime's Approach to, Well, Everything

Three fiscal quarters into my new role at work I am pleasantly surprised to discover that CDHPs have quietly evolved from a disingenuous cost-sharing scheme foisted on workers by employers (see the Pollyannaish video, below) to a proactive, multifaceted approach intended to achieve “a pluralistic system that empowers patients and demands accountability from individuals and the health system, while adequately supporting the needs of the disadvantaged.”

Moreover, the criteria for determining whether or not these lofty goals are met are both simple and progressive:

1. Consumer-driven programs must encourage and attract enrollment from the sickest members as well as the healthy.
2. Consumer-driven programs must work for those members who don’t want to get involved in decision-making as well as for those who do.

Granted, the above is only Wye River Group’s take on the matter, but given that it comes directly from their An Employers’ Guide to Healthcare Consumerism which was published in 2006 I am inclined to take them at their word and note this as a sea change in suppliers’ attitudes towards the healthcare crisis in this country.

What Wye River Group refers to as healthcare consumerism is a synthesis of old and new ideas as well as delivery and payment models in the healthcare market. It encompasses consumer-driven health plans, value-based benefit design techniques, and good old-fashioned managed care (as opposed to managed access and/or managed costs).

Despite its name, healthcare consumerism isn’t mutually exclusive of government involvement. Indeed, the techniques it espouses could go a long way towards making the already superior healthcare model in place for US military veterans that much more cost-effective and efficient – not to mention portable to state and local governments and private industry.

There are few people as skeptical of for-profit payers as I am, but in light of this evolution of thought in the consumer-driven healthcare space I am open to – and hopeful at the prospect of being – proven wrong.

Baby boomers have started reaching their retirement age in 2011, and with over 78 million of them as patients they will require care during their senior years.  Baby boomers are commonly known as the more self-reliant, gadget early adopters, and active individuals.  But with their high population number they are bound to put demand more from our health system.

In the current care delivery model we have today for senior citizens, nursing homes, hospital visits and assisted living are costly to both payers and patients.  And for that reason payers are looking to see what cost benefits would caring for patients at home and support their independences bring.

There are many reasons for the increase in demand for home health services and following is a short list to name a few:

Lower costs:  As patients are being treated at home, this alternate care location eliminates the costs associated with transport, and beds associated with charges inside a healthcare facility.

Telemedicine:  Baby boomers are known for being early adopters of technology and gadgets.  And with many of the capabilities of today’s electronic medical devices and smart phones, patients are able to remotely transmit data and have a care giver review it as part of their care. In addition, patients can even have access to a nurse and physician through video conferencing and be able to discuss their health issues from the comfort of their home.

Active life style:  As more baby boomers continue to enter retirement at a rate of 7,000 a day, many are continuing to stay active.  This most likely influences their decision to try to seek receiving care in the home instead of in a healthcare facility.

Technology:  In this area, we see that both patients and care providers benefiting from some of the technological advancements.  For home health service providers, mobile devices, and tablets have provided many much needed improved efficiencies.  Some of the examples are accessing records remotely, and transmitting information on the patient’s visit real time.

As we to see a shift toward keeping patients healthier and out of hospitals, it will become more critical for patients to receive care, participate in wellness programs and receive preventable care that can help ensure a healthier life.  Homecare services will play a significant role in helping patients with their health needs and keep healthcare costs down by reducing long/short term stays in nursing home and other assisted facilities.

More independent physicians are being solicited to connect to a community, local, or state HIE.  Since many of these entities have gone live in higher numbers this past year, and continue to see an increase especially due to the meaningful use stage 2 proposed ruling, physicians will continue to find themselves with several vendors and options from which to choose. Below are a few important areas of considerations for all providers taking the next steps forward in data exchange:

Connectivity with other existing community based (private HIEs) and state or national (NHIN):

One of the core components and purposes of an HIE is to provide continuous availability to medical records, enabling physicians to make better treatment decisions and deliver a higher quality of care in a more efficient manner.  When joining an HIE, providers must also consider what other entities the HIE can use to locate charts electronically.

Contracts:

When joining an HIE, a physician would be subscribing to the services that will be offered.  They will also be agreeing to local state laws around HIEs as well as specific liability and data security requirements set forth by the HIE. These contracts must be reviewed in great details, as they are very complex. The binding legal document will address privacy, security concerns, technical issues, as well as any obligations that maybe associated with early termination.

Usability of system and patient information:

There are several different methods of accessing a patient’s chart through an HIE.  One of the most commonly used and simplest method is via the HIE’s web portal which allows the physician to connect securely and perform record searches for patients.  This set up does not require any special software or interfacing to gain access to the record information.  Another access method that provides a seamless and common interface is through the use of physician’s EHR to request and process incoming patient’s summary chart.  This allows for some of the outside patient information to be combined with current physician’s patient records.  It is important to consider the connectivity model that can help create efficiencies for the organization, so both must be evaluated to ensure the right option is selected.

Value added services:

A great example of how some of the HIE are providing subscribers value added services is what a NC based HIE is doing.  CareConnect Carolinas a local HIE through Carolinas Health System is providing the following services:
·         Comprehensive medication list from SureScipts as well as many other local and national pharmacy networks.
·         Access to patient’s imaging records available through the hospital Information System
·         Access to Lab reports, Transcriptions, letter, Encounter details, Patient facesheet
·         Advanced alerting capabilities such as flags for drug seekers
·         Downloadable CCD (Continuity Care Document)
·         An EHR Lite to assist physicians with Meaningful Use
·         Referral management to digitize the information exchanged during the referral process
·         Web orders for certain labs at some of the health system facilities

There are other health systems that are also providing a PHR access feature for the patients.  This feature provides another method for the patient to be engaged and actively maintain their health record.  It also encourages up to date information even it is manually entered.

Pricing model:

Similar to many of the online subscription based services, HIEs fees are monthly.  Whether it is the physician or health system, they pay a reoccurring monthly fee for the length of the agreement. There is some setup fee associated with most and possibly additional third party charges when interfacing or integrating with an EHR.

Integration capabilities with existing system:

Not all HIEs provide integration with all EHR systems.  Ideally an HIE can provide a strong and tight integration with an EHR product and allow end users to simply use their electronic medical records application which they are already familiar with.  This will enable physicians to simply use the same application to manage patient charts as well as request medical records from an HIE.  But unfortunately, not all HIEs or EHRs allow for this integration.  So for some access to an HIE web portal that provides the ability to print/save the summary record is as far as the system will go.

With the proposed meaningful use stage 2, and 3 there is a stronger emphasis on the electronic exchange of medical records through a qualified Health Information Exchange.  And more physicians and organizations will begin to review some of the available HIEs in their community and state.

For several years now I have benefited from using a centralized to-do list integrated with my Outlook calendar.It offers a complete view of what activities and items I needed to accomplish everyday in an easy to use integrated fashion. But as I started relying more and more on mobile devices and tablets to conduct everyday business, I found out quickly that I needed to begin utilizing different apps that would allow me to easily view my tasks and calendars from any device, at any time.

Fortunately there were several mobile apps that allow me to maintain all my devices in sync with my Outlook tasks, with one of my favorites being toodledo. The toodledo app allows me to apply some of the principles of proper time management outlined in Steven Covey’s “The four discipline of execution,” and allows all of my “toys” to maintain the same list.

But one challenge that some face lies in deciding when to separate and manage multiple to-do lists. For example, for those physicians who are still practicing and also participating in leadership roles, managing their calendar requires a tremendous amount of discipline and time management skills. In a perfect world, a physician’s EHR messages should be able to easily integrate and populate with their Outlook tasks and calendar (securely and without any patient info). Unfortunately, not all systems integrate or sync with Outlook tasks, which means that many times users need to manage multiple lists or else rely on manual synchronization between different systems.

The good news is that many can still successfully and efficiently manage their time even when having to work with multiple lists. Best practice should always be to review your to-do list(s) daily and stick to deadlines, as this will ensure that you are continually monitoring progress are are aware of changing priorities.

I have previously discussed Meaningful Use (MU) criteria for EHRs  (here and here) , and Clinical Decision Support (CDS) (here). These topics are closely linked since the  MU requirements mandate the inclusion of CDS.

On February 22, 2012 the Centers for Medicare and Medicaid Services (CMS) released (in a mere 455 pages in manuscript form) a proposed rule for Stage 2 criteria for qualification of an EHR for the Medicare incentive program. Among many topics, the proposed rule includes some elaboration on the mandatory use of CDS’s as well as issues related to their design and utilization.

This mandate might be viewed in the context of AHRQ’s statement (here) that “Despite thoughtful efforts over the last three decades to translate clinical guidelines into CDS rules, there has not been widespread and successful use of such rules to improve patient care.” Of course limited success to date does not mean that CDS cannot be beneficial in the future. In addition there is a wide range of sophistication in systems that might be called CDS, and which would in part satisfy the MU requirements.

In general the CDS Stage 2 objective is to “Use clinical decision support to improve performance on high-priority health conditions.”  The associated Stage 2 measure as proposed is to, “Implement 5 clinical decision support interventions related to 5 or more clinical quality measures at a relevant point in patient care”, including enabling and implementing drug-drug and drug-allergy interaction checks.  The drug related functionality is intended to provide  information to “advise the provider’s decisions” in prescribing drugs to a patient.

The “advise” component of CDS is a challenging issue since the quality of the advice is a critical element in any CDS system. It is here that the degree to which the provider can and should rely on that advice becomes an important  part of how CDS should be used, and equally how it will actually be used. In this regard it is common for advice systems to have a variety of disclaimers and associated assertions that the professional must in effect second guess the advice given and make their own judgement.

While logical, the value of a CDS that you can’t rely on is at least questionable, as is whether users will always mentally challenge the results. In this regard there are at least three ways in which CDS’s can go astray. One is when the underlying information upon which the advice is based is not strong. A second is that although the underlying data is strong the software is defective. Third, a patient’s individual condition may fall outside of the boundaries for which the information is reasonably correct even though the software is a reliable representation of that data. Moreover, the boundaries of the accuracy domain are often ill defined or not defined at all.

The Stage 2 proposed rule takes an interesting pass at these issues by requiring that each clinical decision support intervention must enable the provider to review all of the following attributes of the intervention:

• Developer of the intervention,
• Bibliographic citation,
• Funding source of the intervention, and
• Release/revision date of the intervention.

Thus instead of just a result (or ranked results perhaps) popping up, the user must be provided with the people and data behind the result, and how old that data is. The proposed rule states that “such information may be valuable so that providers can understand whether the clinical evidence that the intervention represents is current, and whether the development of that intervention was sponsored by an organization that may have conflicting business interests including, but not limited to, a pharmaceutical company, pharmacy benefits management company, or device manufacturer.”

This kind of disclosure is good, but it does not fully account for the degree of validation of the actual results that are generated. It is also proposed that the CDS suggested/advised/proposed interventions must be presented through Certified EHR Technology at a time relevant to direct patient care to a licensed healthcare professional. That professional is then expected to ”exercise clinical judgment.” Therefore it is clear that a CDS cannot be fully relied on, nor can it be a substitute for an appropriate healthcare professional.

The “presented through” requirement suggests that the CDS must be well integrated with the EHR, although this is short of requiring that the CDS actually be part of the EHR. This suggests that EHRs would have to have high flexibility to integrate with the required CDS’s, which conceivably come from different vendors, adding to the challenges of–dare I say it–connectivity itself.

Not all CDS systems will need to be particularly sophisticated. One example given in the proposed rule is a CDS that triggers a point-of-care alert from the EHR that prompts a licensed healthcare professional to ask about influenza immunizations when engaged with a patient 50 years old or older. This kind of little reminder is not fraught with the deeper issues of CDS reliability. More generally it is noted that family health history can be used to inform CDS and patient reminders and patient education. Another suggested CDS application is generic drug and insurance formulary information.

Those who believe that activity should not be confused with results will not find comfort in the observation that for Stage 2 CMS does “not propose to require the provider to demonstrate actual improvement in performance on clinical quality measures” through using a CDS, although improvement should be the provider’s goal.

This proposed rule has a 60 day comment period after which CMS will cogitate on the comments received and publish a final rule with any revisions deemed appropriate. Effected professionals and hospitals will have to watch for this final rule.

Unrelated to MU and CMS, but an interesting example of the intended use of CDS is the approval by the FDA of a software driven mammography pattern recognition system that analyzes the mammography images and marks suspicious areas consistent with breast cancer for review by a radiologist. Of particular interest to me is that the approved method of use is that the radiologist first reads each image in the conventional manner, and then re-examines each region marked by the software analysis before making a decision about the image.  The instructions for use, also posted by the FDA, include important warnings in this regard including that the marked images do not have the level of detail of the original mammogram and that their only purpose is to provide a reference for the location of the auto-generated marks. Further it is stated that the algorithm will not mark all regions that contain cancer and will mark regions that do not contain cancer. As a result the presence of a mark only indicates that a radiologist should review the marked region again to avoid a potential oversight, and the absence of a mark should not dissuade a radiologist from investigating their own suspicious findings.

 Thus the intended use clearly states that the automated read is not sufficiently reliable to be used as a primary analysis, or perhaps that the manufacturer doesn’t want to take on the responsibility of primary analysis, or that the FDA would not accept a claim of primary analysis. It is also possible that radiologists are able to protect their image reading turf by discouraging reliance on automated systems. In any case, the result is a CDS system that is not primary, and cannot be totally relied on.

The next questions then are how will it actually be used, and to the degree that it may be relied on, how good is it? An associated question of interest is whether radiologists would chose to not follow-up on a flagged region that they didn’t think was suspicious, or would they always pursue the next steps which may include biopsy. Since those next steps involve the potential for both physical and psychological adverse outcomes, pursuing that which doesn’t need to be pursued is not without consequence.

The experiences of radiologists using the system would also be of interest. Even doing what the instructions say, the radiologist may find that the system only finds what they have already found, and/or doesn’t find what they have already found, and/or finds things they didn’t find that are spurious, or really does find important things that they missed. Each possibility and their combination will inform how such systems actually come to be used, or not used.

William Hyman is Professor Emeritus of the Department of Biomedical Engineering at Texas A&M University. He recently retired and has moved to New York City where he continues his professional activities.

I received several items in my email regarding different organizations’ proclamations for 2012.  Most of them predict that 2012 will be the year for mHealth to ‘break-out.’  Here are 5 examples:

1. HIMSS 2012 is focusing on mHealth with several sessions and will have a kiosk on the vendor floor which features speakers on the mobile aspect of healthcare
2. AAMI has published in their IT World column a synopsis of mHealth (requires login credentials)
3. Here in Europe, the Mobile World Congress, Barcelona Feb 2012, sponsored by the GSM Association, has a track devoted to mHealth (filter for Mobile Health), a day of demonstrations and a specific plan on embedded mobile medical functionality.
4. Additionally, the FDA has come out with draft guidance and has promised final guidance regarding mobile medical apps.  The European Commission has entered into an MOU with the HHS to work together on the regulatory aspects of healthcare.  I wouldn’t be surprised if they come out with similar regulatory guidance regarding mHealth as that promulgated by the FDA.
5. Lastly, from a market perspective, “The mobile health market has a year-over-year growth rate of around 17% since 2010 and is estimated to be worth $2.1 billion at the end of 2011. The report also said the mobile health market is expected to grow …. nearly 22% from 2012 to 2014.”

One might ask, what is mHealth?  It has many different definitions and from a product offering perspective could range from texting information on a mobile phone to a provider and/or specifying a provider geographical location to a patient to bi-directional interaction with a medical device to/from an electronic medical record application via mobile phone or telecommunications frequencies (or the medical device could be embedded with the mobile telecommunication appliance).  As with the traditional Healthcare industry, as one progresses up the interaction functionality chain, the design and interoperability gets more complex.  Most of the latest news items I read about successful mHealth applications describe the ‘easier’ applications:  texting, scheduling, location, etc.  There is still growth and development in the marketplace for interactive medical-device integrated/connected products.  Additionally, from a market perspective, most of the current product offerings are proprietary in nature and vertically integrated.

Mobile telecommunication vendors are keenly interested in providing for the healthcare market.  They are closely watching as well as working to influence the regulatory environment.  From a provider perspective, this means adding another large player to the mix.  You may already provide some internal mobile telecommunications support, but providing healthcare monitoring over that infrastructure changes the rules of the game.  In addition, the mobile telecommunications market plays to the consumer market, which has faster turnaround times, and higher customer expectations.  The consumer market expects the ability to smoothly transition service when changing a ‘product provider.’  In addition, with social media, the pressures are higher; witness the recent policy and product turnaround of Verizon to a charge for customers using a specific billing mechanism.  The healthcare provider is not used to this type of oversight or pressure yet.

Down in the healthcare provider trenches, testing remote monitoring and the use of mobile telecommunications offerings continues.  Here in Europe there are two larger projects that are interested in demonstrating the efficacy of remote monitoring.  One, the Whole System Demonstrator based in England and their National Health System (NHS),  has just published its preliminary results.  Another, Renewing Health, is based on a nine European country pilot for remote monitoring of chronic diseases. In the case of the Whole System Demonstrator, initial results have been very positive for the clinical outcomes regarding the use of remote monitoring models for chronic disease management with a “15% reduction in A&E visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tariff costs” along with a “45% reduction in mortality rates.”

Renewing Health is still in its trial period, however, the initial technical results have been published.  A basic summary of the technical aspects of the nine solutions follows:

1. All pilots sites used proprietary solutions,
2. The most widely used standards were protocol and telecommunication standards, but even with some of those standards, there were issues with product development and rol-lout.  This has resulted in some technology system re-design as well increased expenditure on patient education.
3. Moreover, the market has dealt some variables, by either not continuing distribution of a mobile phone model or changing the implementation of a medical device transport protocol.  Additionally, intermittent wireless coverage and/or limited bandwidth for a teleconferencing function have led to design changes or required infrastructure upgrades.
4. The market has a dearth of standards-based products for purchase.  In Europe this is complicated by language requirements (most of the countries have healthcare systems which specify that products be purchased which have markings and documentation in their national language – this is for ease of use as well as cultural preservation goals).
5. Another big issue is system ergonomics with respect to patient cohort.  Mobile phones with small screens and small input interfaces (small mobile phone keyboards) don’t work well with more elderly patients.

This project will be ongoing until 2013 and at the end the results are hoped to strengthen the hypothesis that well designed remote monitoring programs for chronic disease management is as or more effective than care delivered in the traditional manner.  There should also be some interesting results from a technical perspective.  The market is slowly moving towards providing more standards-based products, however, for the purposes of this project, timing did not allow more adoption of those types of products.

So, with all of the activity described above what should healthcare providers do?  I suggest the following:

1. Keep current on the mobile telecommunications arena both in product offerings and regulatory oversight.  With the MDDS and the draft mobile medical apps guidance, the FDA has signaled they will be interested in regulating some aspects of healthcare delivery.   If you as a healthcare provider adopt mHealth solutions, this will increase the complexity of providing and servicing/maintaining healthcare products from the provider.  You control your enterprise, but as the information goes outside the enterprise to the shared infrastructures, you lose that control.  Therefore, you may not be able to guarantee the types of performance or response that may be the norm within your enterprise.  Agreements with the third party infrastructure entities will become paramount to ensure good performance and in the end good relationships with your customers:  the patients and clinicians.  Moreover, in light of the recent FDA guidance, understanding the infrastructure path of your mHealth solutions so that you meet any regulatory burden will become even more important as you embark outside of your enterprise.
2. Consider specifying standards for data and communication across each interface (example: Continua Guidelines, IHE-PCD) in your acquisition documents.  As with traditional medical device connectivity in your enterprise, the more you can decouple the medical device choice from the other parts of a connectivity solution, the more flexibility you have to make decisions based on the quality of the different parts of the system.  In the future, this may avert having to redesign, augment and/or replace the whole system from medical device to electronic medical record application due to a technology refresh of one of the manufacturers in the system.
3. Providers are under a lot of pressure to control healthcare costs in all parts of the world.  As remote monitoring pilot results become more prevalent, it will be expected that providers adopt some of these mobile health solutions.  Timing of your adoption will become very important as this is a fast moving train.  The product cycles for mHealth can be 6 months to 1 year.  This is much faster than your usual IT infrastructure refresh cycle which is already faster than your medical device/technology refresh cycle.  Although many of the traditional medical device companies are migrating to a software based solution and a refresh cycle similar to that in the IT industry, they may not be as ready for the mHealth refresh frequency cycle.  This may slow down in the US and Europe due to more regulatory oversight, however, the development outside those areas of the world does not have as much regulatory oversight, so some of the more interesting products may be developed outside of the geographical areas we’ve become accustomed to in the US and Europe.  If you have a ‘wandering clinician’ or patient, they may be the one who introduces or demands a specific functionality to your enterprise from their wanderings.
4. If your mHealth solution implementation is successful, be prepared to expand.  It is estimated that 80% of healthcare costs are borne by 20% of the population and most of this is due to the management of chronic diseases.    Remember, as with most endeavors, more is demanded of you once you succeed.

So is 2012 the year of mHealth?  Perhaps.  If anything, it will be another exciting year for mobile technology and the convergence of the consumer and healthcare industries.  It will be bumpy, but in the end, it should be better for the consumer who usually also happens to be the patient.

Bridget A. Moorman, CCE, is president of BMoorman Consulting, LLC, providing consulting to healthcare providers, standards promulgation organizations and medical device and information technology companies regarding their medical device integration strategies.  She can be reached via email  or at her website.

A recent Class I recall (not pictured) of a medical monitor with a hospital network connected central station stimulates some generalities about software, “fixes”, and connectivity. (Class I recalls are defined by the FDA as  a situation in which there is a reasonable probability that the use of, or exposure to, a violative product will cause serious adverse health consequences or death.)

The use of the product in question was given as:

• a networked solution system used to monitor a patient’s vital signs and therapy, control alarms, review Web-based diagnostic images, and access patient records. The number of monitored vital signs can be increased or decreased based on the patient’s needs

Curiously only one customer was identified as having received the product, or at least this particular version of the product. While the manufacturer and product in question is a matter of public record, and available at the link, I chose not to include it here because my objective is not to repeat the recall information, but to suggest the reasons for the recall, an associated labeling issue, and offer some general lessons.

The reason given for the recall had two seemingly separate parts. The first is that “The weight-based drug dosage calculation may indicate incorrect recommended values, including a drug dosage up to ten times the indicated dosage”. This sounds like a software problem yet the fix was not to “upgrade” the software but to suggest a workaround. (I love the term upgrade to when applied to fixing something that doesn’t actually work!)  According to the FDA the firm’s letter stated that “users should enter the patient’s weight by way of the admin/demographics screen to ensure the drug dosage is calculated as intended.” (I did not find the firm’s letter on its website, but it might be one of those hidden page situations since I did find, with a struggle, two other recalls, though using the search term “recall” produced no results). Again speculating, the workaround sounds like a user dependent way to do something that was supposed to happen automatically. At least part of the value of automation is largely diminished, and opportunities for use error increased, when such additional demands are placed on the user.

The second reason given for the recall was that there may be a 5-10 second delay between the electrocardiogram and blood pressure curves (waveforms) at the central station.   This is an interesting technical issue that may be related to software and/or communication protocols. In either case it illustrates that multiple data streams may only be useful if they are properly timed stamped, and then properly aligned at the receiver. Out-of-sync data when subsequently processed either by eye, or automatically, can give erroneous and misleading results that might appear to be correct, i.e. the results could be in the category of erroneous but believable.

For one or both reasons the FDA found that, “This product may cause serious adverse health consequences, including death.” Yet it should be noted that this was a voluntary recall, as most recalls are, despite the fact that people who surely know better reported this as “FDA recalls…”

The FDA announcement goes on to say that the company pointed out that the instructions for use state that: ”For primary monitoring and diagnosis of bedside patients, use the bedside monitor. Use the…Central Station only for remote assessment of a patient’s status.” This sentence seems to be illustrative of the fundamental problem of remote information receivers and integrators that carry a disclaimer that in sum says that you shouldn’t rely on them. But isn’t the ability to rely on it exactly why you bought it? Moreover, promotional materials available on the web do not appear to echo this disclaimer. For example it is stated that ”Applications…enhance patient care management by providing rapid assessment, decision support and clinical reporting.” Does that sound like it isn’t for primary diagnosis? Or does “Data accessible from the…Central Station includes real-time waveforms” sound like those waveforms shouldn’t be used for primary monitoring? For one more example it is said that “arrhythmia events are detected with an unprecedented degree of accuracy.” Accuracy is certainly a good thing, but detecting arrhythmias at the central station when only the beside monitor is to be used for “primary monitoring and diagnosis” appears to be less than highly useful.

Furthermore the statement that the central station is only for remote assessment seems both definitional and contradictory. It is obviously for remote assessment–because it is a central station and thus remote! But then what does “assessment of the patient’s status” mean if not monitoring and diagnosis?

The disclaimer game has been addressed in these pages before. Here it seems to involve a product that is being marketed, sold and bought for exactly the reasons that the manufacturer is saying it shouldn’t be used. I didn’t spot the disclaimer language in any of the promotional materials, but maybe it is there somewhere.

So, we have here an apparent example of software driven miscalculations, network transported data that is not time synchornized, and a reminder not to use the central station for primary assessment. Important examples to remember as we charge ahead with software driven networked solutions.

[The products in the photo with this post above are not associated with the recall discussed, and are for illustrative purposes only.]

William Hyman is Professor Emeritus of the Department of Biomedical Engineering at Texas A&M University. He recently retired and has moved to New York City where he continues his professional activities.

For a month in advance, the people who filled the courtroom had been told by the press that they would see the man who was a greedy enemy of society; but they had come to see the man who had invented Rearden Metal.

He stood up, when the judges called upon him to do so. He wore a grey suit, he had pale blue eyes and blond hair; it was not the colours that made his figure seem icily implacable, it was the fact that the suit had an expensive simplicity seldom flaunted these days, that it belonged in the sternly luxurious office of a rich corporation, that his bearing came from a civilised era and clashed with the place around him.

The crowd knew from the newspapers that he represented the evil of ruthless wealth; and - as they praised the virtue of chastity, then ran to see any movie that displayed a half-naked female on its posters - so they came to see him; evil, at least, did not have the stale hopelessness of a bromide which none believed and none dared to challenge. They looked at him without admiration - admiration was a feeling they had lost the capacity to experience, long ago; they looked with curiosity and with a dim sense of defiance against those who had told them that it was their duty to hate him.

A few years ago, they would have jeered at his air of self-confident wealth. But today, there was a slate-grey sky in the windows of the courtroom, which promised the first snowstorm of a long, hard winter; the last of the country's oil was vanishing, and the coal mines were not able to keep up with the hysterical scramble for winter supplies. The crowd in the courtroom remembered that this was the case which had cost them the services of Ken Danagger. There were rumours that the output of the Danagger Coal Company had fallen perceptibly within one month; the newspapers said that it was merely a matter of readjustment while Danagger's cousin was reorganising the company he had taken over. Last week, the front pages had carried the story of a catastrophe on the site of a housing project under construction: defective steel girders had collapsed, killing four workmen; the newspapers had not mentioned, but the crowd knew, that the girders had come from Orren Boyle's Associated Steel.

They sat in the courtroom in heavy silence and they looked at the tall, grey figure, not with hope - they were losing the capacity to hope - but with an impassive neutrality spiked by a faint question mark; the question mark was placed over all the pious slogans they had heard for years.

The newspapers had snarled that the cause of the country's troubles, as this case demonstrated, was the selfish greed of rich industrialists; that it was men like Hank Rearden who were to blame for the shrinking diet, the falling temperature and the cracking roofs in the homes of the nation; that if it had not been for men who broke regulations and hampered the government's plans, prosperity would have been achieved long ago; and that a man like Hank Rearden was prompted by nothing but the profit motive. This last was stated without explanation or elaboration, as if the words "profit motive" were the self-evident brand of ultimate evil.

The crowd remembered that these same newspapers, less than two years ago, had screamed that the production of Rearden Metal should be forbidden, because its producer was endangering people's lives for the sake of his greed; they remembered that the man in grey had ridden in the cab of the first engine to run over a track of his own Metal; and that he was now on trial for the greedy crime of withholding from the public a load of the Metal which it had been his greedy crime to offer in the public market.

According to the procedure established by directives, cases of this kind were not tried by a jury, but by a panel of three judges appointed by the Bureau of Economic Planning and National Resources; the procedure, the directives had stated, was to be informal and democratic. The judge's bench had been removed from the old Philadelphia courtroom for this occasion, and replaced by a table on a wooden platform; it gave the room an atmosphere suggesting the kind of meeting where a presiding body puts something over on a mentally retarded membership.

One of the judges, acting as prosecutor, had read the charges.
"You may now offer whatever plea you wish to make in your own defence," he announced. Facing the platform, his voice inflectionless and peculiarly clear, Hank Rearden answered:
"I have no defence."
"Do you --" The judge stumbled; he had not expected it to be that easy. "Do you throw yourself upon the mercy of this court?"
"I do not recognise this court's right to try me."
"What?"
"I do not recognise this court's right to try me."
"But, Mr. Rearden, this is the legally appointed court to try this particular category of crime."
"I do not recognise my action as a crime."
"But you have admitted that you have broken our regulations controlling the sale of your Metal."
"I do not recognise your right to control the sale of my Metal."
"Is it necessary for me to point out that your recognition was not required?"
"No. I am fully aware of it and I am acting accordingly."

He noted the stillness of the room. By the rules of the complicated pretence which all those people played for one another's benefit, they should have considered his stand as incomprehensible folly; there should have been rustles of astonishment and derision; there were none; they sat still; they understood.
"Do you mean that you are refusing to obey the law?" asked the judge.
"No. I am complying with the law - to the letter. Your law holds that my life, my work and my property may be disposed of without my consent. Very well, you may now dispose of me without my participation in the matter. I will not play the part of defending myself, where no defence is possible, and I will not simulate the illusion of dealing with a tribunal of justice."
"But, Mr. Rearden, the law provides specifically that you are to be given an opportunity to present your side of the case and to defend yourself."
"A prisoner brought to trial can defend himself only if there is an objective principle of justice recognised by his judges, a principle upholding his rights, which they may not violate and which he can invoke. The law, by which you are trying me, holds that there are no principles, that I have no rights and that you may do with me whatever you please. Very well. Do it." "Mr. Rearden, the law which you are denouncing is based on the highest principle - the principle of the public good."
"Who is the public? What does it hold as its good? There was a time when men believed that 'the good' was a concept to be defined by a code of moral values and that no man had the right to seek his good through the violation of the rights of another. If it is now believed that my fellow men may sacrifice me in any manner they please for the sake of whatever they deem to e their own good, if they believe that they may seize my property simply because they need it - well, so does any burglar. There is only this difference: the burglar does not ask me to sanction his act."

A group of seats at the side of the courtroom was reserved for the prominent visitors who had come from New York to witness the trial. Dagny sat motionless and her face showed nothing but a solemn attention, the attention of listening with the knowledge that the flow of his words would determine the course of her life. Eddie Willers sat beside her. James Taggart had not come. Paul Larkin sat hunched forward, his face thrust out, pointed like an animal's muzzle, sharpened by a look of fear now turning into malicious hatred. Mr. Mowen, who sat beside him, was a man of greater innocence and smaller understanding; his fear was of a simpler nature; he listened in bewildered indignation and he whispered to Larkin, "Good God, now he's done it! Now he'll convince the whole country that all businessmen are enemies of the public good!"

"Are we to understand," asked the judge, "that you hold your own interests above the interests of the public?"
"I hold that such a question can never arise except in a society of cannibals."
"What ... do you mean?"
"I hold that there is no clash of interests among men who do not demand the unearned and do not practice human sacrifices."
"Are we to understand that if the public deems it necessary to curtail your profits, you do not recognise its right to do so?"
"Why, yes, I do. The public may curtail my profits any time it wishes - by refusing to buy my product."
"We are speaking of ... other methods."
"Any other method of curtailing profits is the method of looters - and I recognise it as such."
"Mr. Rearden, this is hardly the way to defend yourself."
"I said that I would not defend myself."
"But this is unheard of! Do you realise the gravity of the charge against you?"
"I do not care to consider it."
"Do you realise the possible consequences of your stand?"
"Fully."
"It is the opinion of this court that the facts presented by the prosecution seem to warrant no leniency. The penalty which this court has the power to impose on you is extremely severe."
"Go ahead."
"I beg your pardon?"
"Impose it."
The three judges looked at one another. Then their spokesman turned back to Rearden. "This is unprecedented," he said.
"It is completely irregular," said the second judge. "The law requires you submit to a plea in your own defence. Your only alternative is to state for the record that you throw yourself upon the mercy of the court."
"I do not."
"But you have to."
"Do you mean that what you expect from me is some sort of voluntary action?"
"Yes."
"I volunteer nothing."
"But the law demands that the defendant's side be represented on the record."
"Do you mean that you need my help to make this procedure legal?"
"Well, no ... yes ... that is, to complete the form."
"I will not help you."
The third and youngest judge, who had acted as prosecutor snapped impatiently, "This is ridiculous and unfair! Do you want to let it look as if a man of your prominence had been railroaded without a --" He cut himself off short. Somebody at the back of the courtroom emitted a long whistle.
"I want," said Rearden gravely, "to let the nature of this procedure appear exactly for what it is. If you need my help to disguise it - I will not help you."
"But we are giving you a chance to defend yourself - and it is you who are rejecting it."
"I will not help you to pretend that I have a chance. I will not help you to preserve an appearance of righteousness where rights are not recognised. I will not help you to preserve an appearance of rationality by entering a debate in which a gun is the final argument. I will not help you to pretend that you are administering justice."
"But the law compels you to volunteer a defence!"
There was laughter at the back of the courtroom.
"That is the flaw in your theory, gentlemen," said Rearden gravely, "and I will not help you out of it. If you choose to deal with men by means of compulsion, do so. But you will discover that you need the voluntary co-operation of your victims, in many more ways than you can see at present. And your victims should discover that it is their own volition - which you cannot force - that makes you possible. I choose to be consistent and I will obey you in the manner you demand. Whatever you wish me to do, I will do it at the point of a gun. If you sentence me to jail, you will have to send armed men to carry me there - I will not volunteer to move. If you fine me, you will have to seize my property to collect the fine - I will not volunteer to pay it. If you believe that you have the right to force me - use your guns openly. I will not help you to disguise the nature of your action."
The eldest judge leaned forward across the table and his voice became suavely derisive: "You speak as if you were fighting for some sort of principle, Mr. Rearden, but what you're actually fighting for is only your property, isn't it?"
"Yes, of course. I am fighting for my property. Do you know the kind of principle that represents?"
"You pose as a champion of freedom, but it's only the freedom to make money that you're after."
"Yes, of course. All I want is the freedom to make money. Do you know what that freedom implies?"
"Surely, Mr. Rearden, you wouldn't want your attitude to be misunderstood. You wouldn't want to give support to the widespread impression that you are a man devoid of social conscience, who feels no concern for the welfare of his fellows and works for nothing but his own profit."
"I work for nothing but my own profit. I earn it."


There was a gasp, not of indignation, but of astonishment, in the crowd behind him and silence from the judges he faced. He went on calmly:
"No, I do not want my attitude to be misunderstood. I shall be glad to state it for the record. I am in full agreement with the facts of everything said about me in the newspapers - with the facts, but not with the evaluation. I work for nothing but my own profit - which I make by selling a product they need to men who are willing and able to buy it. I do not produce it for their benefit at the expense of mine, and they do not buy it for my benefit at the expense of theirs; I do not sacrifice my interests to them nor do they sacrifice theirs to me; we deal as equals by mutual consent to mutual advantage - and I am proud of every penny that I have earned in this manner. I am rich and I am proud of every penny I own. I made my money by my own effort, in free exchange and through the voluntary consent of every man I dealt with - voluntary consent of those who employed me when I started, the voluntary consent of those who work for me now, the voluntary consent of those who buy my product. I shall answer all the questions you are afraid to ask me openly. Do I wish to pay my workers more than their services are worth to me? I do not. Do I wish to sell my product for less than my customers are willing to pay me? I do not. Do I wish to sell it at a loss or give it away? I do not. If this is evil, do whatever you please about me, according to whatever standards you hold. These are mine. I am earning my own living, as every honest man must. I refuse to accept as guilt the fact of my own existence and the fact that I must work in order to support it. I refuse to accept as guilt the fact that I am able to do it better than most people - the fact that my work is of greater value than the work of my neighbours and that more men are willing to pay me. I refuse to apologise for my ability - I refuse to apologise for my success - I refuse to apologise for my money. If this is evil, make the most of it. If this is what the public finds harmful to its interests, let the public destroy me. This is my code - and I will accept no other. I could say to you that I have done more good for my fellow men than you can ever hope to accomplish - but I will not say it, because I do not seek the good of others as a sanction for my right to exist, nor do I seek the good of others as a sanction for my right to exist, nor do I recognise the good of others as a justification for their seizure of my property or their destruction of my life. I will not say that the good of others was the purpose of my work - my own good was my purpose, and I despise the man who surrenders his. I could say to you that you do not serve the public good - that nobody's good can be achieved at the price of human sacrifices - that when you violate the rights of one man, you have violated the right of all, and a public of rightless creatures is doomed to destruction. I could say to you that you will and can achieve nothing but universal devastation - as any looter must, when he runs out of victims. I could say it, but I won't. It is not your particular policy that I challenge, but your moral premise. If it were true that men could achieve their good by means of turning some men into sacrificial animals, and I were asked to immolate myself for the sake of creatures who wanted to survive at the price of my blood, if I were asked to serve the interests of society apart from, above and against my own - I would refuse. I would reject it as the most contemptible evil, I would fight it with every power I possess, I would fight the whole of mankind, if one minute were all I could last before I were murdered, I would fight in the full confidence of the justice of my battle and of a living being's right to exist. Let there be no misunderstanding about me. If it is now the belief of my fellow men, who call themselves the public, that their good requires victims, then I say: The public good be damned, I will have no part of it!"

The crowd burst into applause.

Rearden whirled around, more startled than his judges. He saw face that laughed in violent excitement, and faces that pleaded for help; he saw their silent despair breaking out into the open; he saw the same anger and indignation as his own, finding release in the wild defiance of their cheering; he saw the looks of admiration and the looks of hope. There were also the face of loose-mouthed young men and maliciously unkempt females, the kind who led the booing in newsreel theatres at any appearance of a businessman of the screen; they did not attempt a counter-demonstration; they were silent.

As he looked at the crowd, people saw in his face what the threats of the judges had not been able to evoke: the first sign of emotion. It was a few moments before they heard the furious beating of a gavel upon the table and one of the judges yelling:
" -- or I shall have the courtroom cleared!"
As he turned back to the table, Rearden's eyes moved over the visitor's section. His glance paused on Dagny, a pause perceptible only to her, as if he were saying: It works. She would have appeared calm except that her eyes seemed to have become too large for her face. Eddie Willers was smiling the kind of smile that is a man's substitute for breaking into tears. Mr. Mowen looked stupefied. Paul Larkin was staring at the floor. There was no expression on Bertram Scudder's face - or on his wife, Lillian's. She sat at the end of a row, her legs crossed, a mink stole slanting from her right shoulder to her left hip; she looked at Rearden, not moving.

In the complex violence of all the things he felt, he had time to recognise a touch of regret and longing: there was a face he had hoped to see, had looked for from the start of the session, had wanted to be present more than any other face around him. But Francisco d'Anconia had not come.
"Mr Rearden," said the eldest judge, smiling affably, reproachfully and spreading his arms, "it is regrettable that you should have misunderstood us so completely. That's the trouble - that businessmen refuse to approach us in a spirit of trust and friendship. They seem to imagine that we are their enemies. Why do you speak of human sacrifices? What made you go to such an extreme? We have no intention of seizing your property or destroying your life. We do not seek to harm your interests. We are fully aware of your distinguished achievements. Our purpose is only to balance social pressures and do justice to all. This hearing is really intended, not as a trial, but as a friendly discussion aimed at mutual understanding and co-operation."
"I do not co-operate at the point of a gun."
"Why speak of guns? This matter is not serious enough to warrant such references. We are fully aware that the guilt in this case lies chiefly with Mr. Kenneth Danagger, who instigated this infringement of the law, who exerted pressure upon you and who confessed his guilt by disappearing his guilt by disappearing in order to escape trial."
"No. We did it by equal, mutual, voluntary agreement."
"Mr. Rearden," said the second judge, "you may not share some of our ideas, but when all is said and done, we're all working for the same cause. For the good of the people. We realise that you were prompted to disregard legal technicalities by the critical situation of the coal mines and the crucial importance of fuel to the public welfare."
"No. I was prompted by my own profit and my own interests. What effect it had on the coal mines and the public welfare is for you to estimate. That was not my motive."
Mr. Mowen stared dazedly about him and whispered to Paul Larkin, "Something's gone screwy here."
"Oh, shut up!" snapped Larkin.
"I am sure, Mr. Rearden," said the eldest judge, "that you do not really believe - nor does the public - that we wish to treat you as a sacrificial victim. If anyone has been laboring under such a misapprehension, we are anxious to prove that it is not true."

The judges retired to consider their verdict. They did not stay out long. They returned to an ominously silent courtroom - and announced that a fine of $5,000 was imposed on Henry Rearden, but that the sentence was suspended. Streaks of jeering laughter ran through the applause that swept the courtroom. The applause was aimed at Rearden, the laughter - at the judges.

Rearden stood motionless, not turning to the crowd, barely hearing the applause. He stood looking at the judges. There was no triumph in his face, no elation, only the still intensity of contemplating the enormity of the smallness of the enemy who was destroying the world. He felt as if, after a journey of years through a landscape of devastation, past the ruins of great factories, the wrecks of powerful engines, the bodies of invincible men, he had come upon the despoiler, expecting to find a giant - and had found a rat eager to scurry for cover at the first sound of a human step. If this is what has beaten us, he thought, the guilt is ours.

He was jolted back into the courtroom by the people pressing to surround him. He smiled in answer to their smiles, to the frantic tragic eagerness of their faces; there was a touch of sadness in his smile.
"God bless you, Mr. Rearden!" said an old woman with a ragged shawl over her head. "Can't you save us, Mr. Rearden? They're eating us alive, and it's no use fooling anybody about how it's the rich that they're after - do you know what's happening to us?"
"Listen, Mr. Rearden," said a man who looked like a factory worker, "it's the rich who're selling us down the river. Tell those wealthy bastards, who're so anxious to give everything away, that when they give away their palaces, they're giving away the skin off our backs." "I know it," said Rearden.
The guilt is ours, he thought. If we who were the movers, the providers, the benefactors of mankind, were willing to let the brand of evil be stamped upon us and silently to bear punishment for our virtues - what sort of "good" did we expect to triumph in the world? He looked at the people around him. They had cheered him today; they had cheered him by the side of the track of the John Galt Line. But tomorrow they would clamour for a new directive from Wesley Mouch and a free housing project from Orren Boyle, while Boyle's girders collapsed upon their heads. They would do it, because they would be told to forget, as a sin, that which had made them cheer Hank Rearden.

Why were they ready to renounce their highest moments as a sin? Why were they willing to betray the best within them? What made them believe that this earth was a realm of evil where despair was their natural fate? He could not name the reason, but he know that it had to be named. He felt it as a huge question mark within the courtroom, which it was now his duty to answer.

This was the real sentence imposed upon him, he thought - to discover what idea, what simple idea available to the simplest man, had made mankind accept the doctrines that led it to self-destruction.

Ministry has been championing “real-time documentation”, that is, the practice of entering patient information into the EHR at the time it is collected. Historically, caregivers have clung to the old process of writing on paper and then re-entering it into the EHR later. Our Nurse Informaticians  are doing the hard work of changing that practice. In the areas where we have seen the change, the nurses are reporting that it has given them more time to spend with their patients. The elimination of transcription also means real-time documentation is a more accurate practice.

The following headline caught my eye as I was reading through my RSS feed:

How to deploy ERP in 120 days

As soon as I read this headline I knew I was going to unleash a rant.

Remember, the HITECH act (aka Meaningful Use) is a an incentive program, not a mandate. As we look at stage 2 we will be evaluating the increasing effort against against the decreasing financial incentive – remember stage 2 is worth less than half than stage 1.

Sure there is a supposed penalty, and we will need to take that into account too. But that penalty, starting in 2015 (or later), will be based on the amount of Medicare increase. Medicare may not be increasing by 2015.

Before I pitch a multi-million dollar effort to the senior management team we have to evaluate the ROI.

The other consideration is how much of the Stage 2 objectives are in synch with our patient care executives vision for clinical IT.

WHAT IS ACUPUNCTURE?
Acupuncture involves stimulating points on the body, using thin, solid, metallic needles that are manipulated by hand or by electrical stimulation. Chinese tradition teaches acupuncture practitioners that the aim is to improve levels of qi, which is considered the energy force behind all life, and restore balance in the opposing forces of yin and yang. The needles are placed along meridians, invisible energy channels described in ancient Chinese manuscripts as running the length of the body.

Building an Evidence Base: Clinical Research Progress
“Our goal is to build a house of evidence,” explains long-time NCCAM grantee Brian Berman, M.D., director of the Center for Integrative Medicine at the University of Maryland School of Medicine.
To date, much of the progress in clinical research on acupuncture has come from an interdisciplinary approach that includes experts in acupuncture, clinical trial methodology, biostatistics, and relevant diseases such as osteoarthritis or carpal tunnel syndrome.
“What we’ve learned so far is that the most promising area for using acupuncture is pain,” says Dr. Nahin. Clinical studies are showing acupuncture’s efficacy for some types of pain, such as back, osteoarthritis, and postoperative pain. For example, a systematic review supports the use of acupuncture for postoperative pain management. An NCCAM-supported Phase III clinical trial led by Dr. Berman showed that acupuncture relieved pain and improved function in patients with knee osteoarthritis when it was used with standard medical care, including anti-inflammatory medications and opioid pain relievers. In a large study published in 2009, researchers found that people suffering from chronic low-back pain who received acupuncture or simulated acupuncture treatments fared better than those receiving only conventional care. Pilot studies have looked at acupuncture in posttraumatic stress disorder and chemotherapy-induced nausea and vomiting. And, the Cochrane Collaboration reviewed 11 randomized trials and found that acupuncture may be a valuable option for patients suffering from tension headaches.
But these clinical outcomes may involve more than acupoints and needles. Other aspects of the acupuncture experience may play important roles in healing, including reassurance provided by the practitioner, expectation of benefit, and the sensory experience elicited by acupuncture needling, which has been called de qi and variously described as aching, dull pain, tingling, or a heaviness. In several recent studies researchers have carefully designed their studies to compare true acupuncture to simulated acupuncture and have tried to mimic the sensory experience of true acupuncture so that patients would be unaware of whether they were receiving true or simulated acupuncture. In some of these studies, such as the 2009 study on low-back pain, both simulated acupuncture and real acupuncture produced greater benefit than standard therapy.

Source:

Sources:
NationalNCCAM, National Institutes of Health
Bethesda, Maryland 20892 USA

Many people take dietary supplements in an effort to be well and stay healthy. With so many dietary supplements available and so many claims made about their health benefits, how can a consumer decide what’s safe and effective? This fact sheet provides a general overview of dietary supplements, discusses safety considerations, and suggests sources for additional information.

Key Points

• Federal regulations for dietary supplements are very different from those for prescription and over-the-counter drugs. For example, a dietary supplement manufacturer does not have to prove a product’s safety and effectiveness before it is marketed.
• If you are thinking about using a dietary supplement, first get information on it from reliable sources. Keep in mind that dietary supplements may interact with medications or other dietary supplements and may contain ingredients not listed on the label.
• Tell your health care providers about any complementary and alternative practices you use, including dietary supplements. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

About Dietary Supplements

© Jupiterimages

Dietary supplements were defined in a law passed by Congress in 1994 called the Dietary Supplement Health and Education Act (DSHEA). According to DSHEA, a dietary supplement is a product that:

• Is intended to supplement the diet
• Contains one or more dietary ingredients (including vitamins, minerals, herbs or other botanicals, amino acids, and certain other substances) or their constituents
• Is intended to be taken by mouth, in forms such as tablet, capsule, powder, softgel, gelcap, or liquid
• Is labeled as being a dietary supplement.

Herbal supplements are one type of dietary supplement. An herb is a plant or plant part (such as leaves, flowers, or seeds) that is used for its flavor, scent, and/or therapeutic properties. “Botanical” is often used as a synonym for “herb.” An herbal supplement may contain a single herb or mixtures of herbs.

Research has shown that some uses of dietary supplements are effective in preventing or treating diseases. For example, scientists have found that folic acid (a vitamin) prevents certain birth defects, and a regimen of vitamins and zinc can slow the progression of the age- related eye disease macular degeneration. Also, calcium and vitamin D supplements can be helpful in preventing and treating bone loss and osteoporosis (thinning of bone tissue).

Research has also produced some promising results suggesting that other dietary supplements may be helpful for other health conditions (e.g., omega-3 fatty acids for coronary disease), but in most cases, additional research is needed before firm conclusions can be drawn.

Source:

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In the past decade,newspaper was ubiquitious to news.We relied on Newspaper everyday to deliver us uptodate news about what was happening not only in the region in which we habitated but also for news from across the world.

NHIN Direct, under the leadership of Dr. Doug Fridsma at the Office of the National Coordinator for Healthcare IT, is now known as The Direct Project.  According to Government Healthcare IT News, “The Direct Project is a streamlined version of the more robust nationwide health information network standards set (NHIN), and will offer physicians and small practices the ability to conduct basic health record exchanges. For example, a primary care physician who is referring a patient to a specialist can use the Direct Project to send a clinical summary of that patient to the specialist, and to receive a summary of the consultation”  Open software is available in both .Net and Java versions. Per http://directproject.org, the Direct Project specifies a simple, secure, scalable, standards-based way for participants to send encrypted health information directly to known, trusted recipients over the Internet.  It relies on the sender pushing information to a recipient, using standard e-mail protocols, and does not rely on a central registry of patients, such as would be found in the NHIN Connect solution.

See also:  http://www.govhealthit.com/newsitem.aspx?nid=75326

http://wordpress.org/news/2010/09/ios-v2-6/

EHR Meaningful Use Press Conference from HHS

I managed to cross off an item on my bucket list over the Easter weekend by attending Bluesfest in Byron Bay. Great music, interesting crowds, and plenty of hemp shirts for sale.

One of the highlights was hearing John Fogerty performing Creedence Clearwater Revival classics in a tightly-packed two-hour set. It was like being transported back to Woodstock, or a Vietnam War protest rally.

You’d think that, playing songs that he first performed more than 40 years ago, Fogerty would be a bit jaded. But he looked incredibly fresh and vibrant as he hopped around the stage playing the riffs and belting out ‘Proud Mary,’ ‘Bad Moon Rising’ and scores of other classics. That fresh look was no doubt helped by the fact that at age 67, he still has a full head of hair (damn him!)

The main reason for that appearance is because, as he pointed out during his performance, he’s only recently begun playing those old songs again. Due to a combination of overexposure and anger over contracts and credits (Fogerty wrote nearly every hit CCR recorded and sang and played lead guitar as well) he refused to play old CCR songs in concert for more than 25 years, as he tried to make a career as a solo artist.

It was his wife who convinced him to pick up the old CCR tunes again a couple of years ago, and, as he told the Bluesfest crowd, he is now having the time of his life, re-embracing the songs he wrote and sang in his youth, and entertaining audiences who were too young to see him perform them when they were new.

There’s a lesson here that can be applied to nearly any business. Even if you’re truly passionate about something, it may be a good idea to lay it aside before it becomes a rut, and try something different for a while. You can then return to that earlier passion with fresh eyes and insights gained from years of experience.

Did you ever get fed up with a youthful pursuit you thought you really loved, or moved on because you thought it was time to grow out of it? I know plenty of people who started out as journalists, and after a few years moved into management because it was the sensible thing to =do. Many of them returned to writing 20 or 30 years later, bringing a varied life experience to the role and displaying a rich storytelling technique that they couldn’t have achieved 20 years earlier.

Read the full story on Smarter Business Ideas 

So you think you’ve finished your studies? You may have graduated years ago, but let me tell you, in today’s economy, school is never out.

If you don’t have it already, you need to develop a philosophy of life-long learning. Things are changing much too fast to rely simply on what you learned at uni or TAFE.

For example, whether you’re a small or a large business, you can’t stick your head in the sand and ignore trends like social media. That means not only mastering existing tools, but staying abreast of emerging tools, as well.

It’s pretty clear that most businesses should have a Facebook page and a Twitter account. But when it comes to using some of the newer social media tools for your business, how do you pick a winner? You need to look at factors such as the take-up rate, how it integrates with other tools, and whether it offers something that is not only different, but hopefully useful, as well.

Google+ is one on the cusp (though, supported by and integrated with the raft of Google tools, it’s a pretty safe bet that it will be there for the long haul).

The location-based tool Foursquare, used by more than 15 million people who check in at locations and share their visits with friends, has had a lot of publicity and has attracted venture capital investment. But how important is it to people to become the ‘mayor’ of frequently visited spots? Are people using it mainly to make their friends jealous about where they can afford to go on a holiday?

A tool that I think ticks more of the boxes is Pinterest, an online pinboard service that, in the words of CBS Moneywatch, “attracts people who need to organize the chaos of Internet-age information overload.”

Pinterest describes itself as a social network meant to connect everyone in the world through the things that they find interesting.

The site lets you create and curate multiple pinboards in any category you can create, as well as following others’ pinboards. It falls somewhere between window shopping and actual collecting. You can log on through Twitter or Facebook, so you can tell your friends and customers about your boards.

At the same time, In contrast to Facebook, Pinterest pinners may end up choosing to follow people they don’t know purely based on the photos they curate, creating seemingly random new networks.

Read the full article on Smarter Business Ideas

By Ray Welling

In the competition between digital natives – Gen Y, which has grown up with online technology and digital immigrants – those of us who can remember typewriters and phones with cords attached – for primacy online, it seems that the digital natives have gained the upper hand.

Think Mark Zuckerberg (Facebook, and a billion dollar online empire by the time he reached his mid-20s) vs. Rupert Murdoch (MySpace, phone hacking scandals, declining dead tree media empire). Or Natalie Tran (24-year old Australian vlogger with 156,000 Twitter followers, more than 400 million YouTube views and a cozy career in the making) against say, Tony Abbott (50-something Australian politician with 56,000 Twitter followers but no YouTube channel).

If you read the media reports on what’s hot on the web, there appears to be a strong relationship between a lack of history and Internet success.

But it’s not that simple.

It can be useful to have a long-term view of the online world, which only a seasoned digital immigrant can have. If you can combine that with knowledge of traditional, pre-Internet business principles, you can look past current fads and build a business model that’s sustainable.

For example, the current obsession with whatever is the latest online application exploding in the public consciousness ignores the fragile nature of web success.

With all the current talk of community-building and developing personal relationships, you’d think the concept was invented by Facebook. Digital natives may be too young to remember, but digital immigrants will recall that when MySpace burst on the scene, it was seen as the long-term future of social media. That is, until Facebook came along.

Early digital immigrants can go back even further and remember GeoCities, an online community where people could create personal pages and create a following of fans, which was all the buzz way back in the 20th century.

And consider the power and ubiquity of the Google empire. It may be hard for digital natives to fathom a time pre-Google, but digital immigrants can remember when Yahoo! was seen as the impregnable leader in search (As an aside, it used its cash reserves to buy GeoCities back in 1999), a crown it took from the equally-invulnerable Alta Vista.

Read the full story on Smarter Business Ideas

We were included in a nice article on EMR consulting and it's impact on adoption.

Waldren says it often becomes a quandary for physicians           because they don’t have the financial resources or desire to pay           for expert advice, but they are reluctant to start the process of EMR           adoption due to fears that the wrong decisions will be made. “You           need to show value, and you need to build trust. Those are the two things           consultants have to answer for,” Waldren emphasizes. “I           do see some uptake [with EMR consultants], but I also see that they           have a difficult marketing challenge ahead of them [with physicians].”

That pretty much encapsulates both the article and our feelings on the subject.  But do click through so you can read my quotes!

Buzz is growing for Sermo, an online information sharing community "developed by physicians, for physicians."  Check it out.

Welcome to the only online community where physicians around the nation exchange the latest medical insights with each other and improve patient outcomes - 24/7.

Link

We've posted on Practice Fusion before here and the feedback we've heard was that using "de-identified" patient data to subsidize a free EHR was going to be a serious problem.  Practice Fusion just announced a partnership with Google wherein the web-based application will still be delivered for free but now it will be subsidized by advertisements that come up based on keywords in the patients' records.  No word as to whether the initial model has been scrapped or if this new concept is complementary.  One thing's for certain, it still raises the hackles of privacy advocates.

"It still comes down to the fact the company is using people's sensitive, personal information for profit," said Allison Knight, staff attorney for the Electronic Privacy Information Center in Washington.

Link

So, I am watching this big football match between Barcelona and Chelsea. Me, 100.000 people at the stadium, and millions at their homes across the World. No football fan would ever want to miss this semi final UEFA Champions League game, which is just a special treat.

Anyway, during the first half an incident happens in the Barcelona’s penalty area. Didier Drogba, Chelsea attacker, was running towards Barcelona’s goal, trying to catch a ball passed to him. He was followed closely by Barcelona’s defender Gerard Pique. However, Barcelona’s goal keeper, Víctor Valdés, got to the ball first, and in the process knocked out Pique. He deliver a forceful blow with his hip to Pique’s head. It was not a pretty sight to see. His head made several uncontrolled movements, first from the blow, and then when he fell to the ground unconscious. OK. So what happens now. Me, I am thinking (and tweeting) they should immobilize this guy immediately, put a cervical collar on as a minimum, and surely not let him continue to play. OK. But what do they do. Some guys from Barcelona’s medical team rush to him, start slapping him. OK. His head is flying in all directions. They are not even considering to maybe at least manually stabilize his neck. So he is lying there unconscious for 30 seconds or so. OK. He starts responding, and all is good for these guys. They get him up on his feet, literally do a 5 second exam on him, and yeah man, no worries you are good to go. Get back in there champ.

Take a look at the video.

Is it just me? Or is this totally unacceptable. And sure, what happens next. He starts feeling quite unwell, and 8 minutes after the incident asks for a substitution. The latest news is that he suffered a light concussion and was being kept overnight in a hospital as a precaution after undergoing medical tests. With the medical care he received on the pitch, he is lucky if you ask me.

Here you have this extremely wealthy club in a sport that is turning billions, with players being super stars, earning more money during one minute of play, than you and me in a year. They are the most valuable assets of their clubs, and look how they are treated. OMG, is this for real. My advice to Pique and his colleagues, guys you have tons of money, get yourselves some private medical professionals who will follow you everywhere.

I really thought that these guys learned something, but it seams I was wrong. The guy who knows how medical teams at football matches suck big time, is Petr Cech, who just happened to be defending Chelsea goal when Pique was knocked out. On 14 October 2006, Cech suffered a serious head injury during a game. He and Reading midfielder Stephen Hunt both challenged for the ball inside Chelsea’s penalty area within the first minute of a league match at the Madejski Stadium. Hunt’s right knee hit Cech’s head, leaving him with a depressed skull fracture. Initially unaware of the seriousness of the injury, the doctors later reported that it nearly cost Cech his life, and as a result of the collision, he suffered intense headaches and was warned by his doctor that returning too early could be fatal. After this incident, the South Central Ambulance Service was heavily criticized. Chelsea’s manager at the time, José Mourinho, was critical of the time it took the ambulance to transfer Cech to hospital and Chelsea submitted an official complaint that led to a Premier League and Football Association review, and subsequently led to advances in emergency medical care in the UK.

Take a look at how Cech’s injury occurred, and “brilliant” care he received during the first minutes.

OK. So they learned something in the UK. And what happened to Cech probably had some influence in saving Fabrice Muamba’s life. He suffered cardiac arrest on 17 March 2012 during the first half of an FA Cup quarter-final match between Bolton and Tottenham Hotspur at White Hart Lane. After receiving lengthy attention on the pitch from medical personnel including a consultant cardiologist who was at the game as a fan, Muamba was taken to the specialist coronary care unit at the London Chest Hospital. Muamba had received numerous defibrillator shocks both on the pitch and in the ambulance, but has recovered well, and on 16 April was discharged from the hospital.

Due to a professional team reacting fast, Muamba’s life was saved.

Unfortunately, we humans are really bad at learning for other people’s mistakes. This is what happened tonight in Barcelona, and what happened just some 10 days ago in Italy. On 14 April 2012, while representing Livorno, Piermario Morosini suffered a cardiac arrest and fell to the ground in the 31st minute of the Serie B match against Pescara. The News agency ANSA reported that a city police car was blocking the stadium’s exit for the ambulance for nearly a minute, but a heart specialist said that the delay made no difference. The delay made no difference. Sure, OK that makes it alright. And what about the quality of CPR provided by the medical team?

What can be seen from the available footage, the medical team was very disorganized. There was chaos on the pitch. No chest compressions were performed for a while, no chest compressions as he was put on the stretcher and transferred to the ambulance, no monitoring, no defibrillator attached, no oxygen attached to the bag valve mask, etc.

What strikes me the most is that we are talking about the best clubs and players in the World. Imagine than what is happening in less wealthy countries and in minor leagues. I am afraid to even think about that.

This post was originally published on Tue, 02/28/2012. However, due to issues with web hosting it has been temporarily removed.

A new iOS app I have been working on with my partners for quite some time, has finally been released today in the iTunes store. This iPad specific app is called AED Trainer and can be purchased on sale for 5.99 USD for a limited time period.

AED Trainer app transforms the iPad into a life-like simulator of automatic external defibrillator (AED), allowing the users to get familiar with these life-saving devices. For those who don’t know, AEDs are electronic devices used to deliver electrical shocks to people suffering from cardiac arrest. Electrical shock, also called defibrillation, represents the only therapy for dangerous heart rhythms such as ventricular fibrillation. It is important to note that these devices are not intended to be used by healthcare professionals only. Quite the contrary, they are predominantly aimed at lay rescuers, so you might have seen them hanging on the walls of airports, train stations, stadiums, and other public places. Everyone should know how to use these devices, because cardiac arrest can happen anywhere, anytime and to anyone, and you might just be the one who can save a life. With the AED Trainer app you can experience how a live AED works, try out different scenarios, and be ready to use an actual device in case of a real emergency.

You can learn more about AEDs by watching our “How to use an AED” video.

Download AED Trainer app from the iTunes store.

I just launched a new mini website called TwittER ReaserchER. It is essentially a directory of emergency physicians across the globe who are using Twitter. The project started during research for an article about use of Twitter among emergency physicians. I started tweeting in 2008, and at that time there were only but a few emergency docs out there, but now we managed to identify almost 700 of them. The results of the analysis we performed on their accounts are currently under review in Emergency Medicine Journal. Hopefully the article will be accepted and published soon, so I can share the results with you.

On the website you can find a list of all the emergency physicians we were able to find using Twitter. Each user is represented by his/hers profile picture. If you click on it, you will be taken to the user’s Twitter profile. The list is constantly updating, and if you are an emergency physician using Twitter or know someone who is, please follow @research_er to get included. On this account we also created lists organizing emergency physicians according to the year they started tweeting. You can easily subscribe to these lists.

On the site you can also see the timeline of tweets from all the emergency physicians. It is updating every hour, so you can use it to follow what emergency physicians are saying on Twitter. This way you can follow them, without even being a registered Twitter user, which you should be!

Hope you like the site. I will try to improve it and add more features soon. Of course, your ideas are always welcomed.

Peeps – sorry for the radio silence. Will make it up to you with this: http://ht.ly/4EMV8

Hew (hyū) v.

 
1. To make or shape with or as if with an ax
2. To cut down with an ax

 

“In every block of marble I see a statue as plain as though it stood before me, shaped and perfect in attitude and action. I have only to hew away the rough walls that imprison the lovely apparition to reveal it to the other eyes as mine see it.” – Michaelangelo

An unfinished Michealangelo sculpture.

I just re-read this quote – I think it is a powerful metaphor for any innovator that is out there trying to change the world.They are the ones that can see the fully defined, fully articulated, and fully functional end product within the building blocks that others pass off as mere landscape material. I think this gift of vision – this ability to “see” what others cannot – and the doggedness to stick to the mindless chipping away until others can see it enough to give you the tools you need to finish it off.

We are privileged to be working on a HUGE project right now with a highly innovative company that sees the value of what we are doing and wants to be a part of changing health care. It has been fun to work with them to begin the process of “hewing” away and to literally see the game changing product we have always seen begin to take shape from the dust, the chipped stone, the dirty hands, and the bleeding fingers. The process of discovery and refinement is almost as fun as seeing how the end product will move people.

I am on an email list of Bill DeMarco’s, a reputable industry insider who has written and consulted extensively in the physician group and medical management space. He recently sent me a note about several physician aggregation events in New Jersey.

For some reason it struck a nerve with me . . . which led me to fire off the response below:

Bill,

I thought we already saw this movie?

My question for you . . . besides banding together in some megagroup – what are these physicians doing to actual change the delivery of medicine? ACO is just the latest buzzword excuse to aggregate physicians under a new moniker and a supposed new model.

I am highly suspect that these physicians are doing anything to change the relationship with their patients, to use enabling technology to create team based care, or actually be accountable for the outcomes they produce. What systems are they using to tie themselves together? What financial alignment do they have? What measures are they using to demonstrate superior outcomes? What about the patient experience – 7 minute visits that push pills as the “treatment” won’t get it done in the future.

I think your closing statement, “Representatives from Summit and Optimus were unavailable for comment” says it all.

Am I seeing this the wrong way? Is there anything new about this model this time around? Am I getting old enough to see these things cycle through?

PS – and no, I don’t mean a wolf. The sheep get nervous and band together waiting to get pounced on by wolves.

I don’t normally respond to the many requests from PR companies that come to me looking for coverage on this blog.

In my experience, they still have a lot to learn when engaging with bloggers in general – I agree with most of Damiens bullet points on pimping stuff.

So this Youtube short from AllScripts breaks the mold just a little bit. As someone who has professionally created this type of material – my comments relate to the medium rather than the message.

• an intriguing opening, a flaccid middle part and a strong ending.
• at just over 5 minutes it’s too long; between 2-3 minutes would have been much better, particularly with the strong messages at either end.
• with reference to the middle bits that flagged, the imagery was just overused; yes, i did like that that zooming in on the screencast, but half the time spent would have been enough. likewise with the medical records library shots.
• I didn’t see any "patients" – and maybe that’s the difference between the Irish Health System and the US Model; all of those empty clinic seats freaked me out a bit!

Overall though – nice try.

Watching the evening news on TV – main story concerned the theft of a laptop holding over 167,000 patient donor records -  this happened in New York on 8th February. Sample data was being used on a new system upgrade that the Board is implementing.

In fairness to the Board, they seem to be doing everything right for a
situation like this. An Emergency telephone number has been setup for
concerned donors and recipients, and CEO Andew Kelly was shown
reassuring and explaining how the people affected will be contacted by
post before the end of the week.

In his words, all IBTS laptops have high levels of encryption, and this
was no exception. Speaking though as individual that tries to donate as often as I can  – I hope my name was not on the damn
laptop, encryption or no…

I’ve written in the past about the blood donor experience
and it has been a positive one. On a business note, I’ve also pitched
an IT security awareness service offering to the Blood Transfusion
Board IT Department – one that had been used elsewhere in the Irish
Health Service.

The unfortunate thing for them is that it follows up on some less than positive
stories that have emerged in the last few months regarding problems with the upgrade of the eProgresa system.

According to that investigation by the Irish Medical News :

The existing Progesa software system used
by the Blood Bank will continue to be used by the IBTS. However, the
IBTS said updating the software to the newer ePro­gesa is no longer an
issue for the moment. It said it would now upgrade its hardware system
on which Progesa sits.

It remains to be seen whether this mishap is related directly to that that system upgrade.

Interested in attending Web2Expo in Berlin which is on from 5th-8th November?

If so – go to the Electric Mill Blog – details for getting  a free ticket are there.

I remember vividly reading about DNA and its mechanisms in James Watson's Double Helix. The unzipping of the two reversed strands interlocked by the strict pairing of nucleotides--adenine to thymine and guanine to cytosine. The complex and choreographed interactions with other molecules leading to the construction of proteins. The systematic beauty at the nucleus of life. It was all engaging enough for me to decide to study Biochemistry at university.

When I finished my degree I worked in international marketing and travelled the world. I was always proud (and grateful!) that English is the most widely spoken language with about 80 percent of the world being able to speak it. But it is not the real lingua franca any more. The most popular language comprises 0s and 1s--the binary language of computers. GB Shaw said America and England were 'separated by the same language,' but the binary language unites the world.

What's more, the two binary languages of DNA nucleotide pairing and computer coding are set dominate the coming decades in a combination of genomics and computer science. David Baltimore said that Biology is today an information science. Indeed, Bioinformatics combines life and computer science so that they are as interlocked as the strands of DNA.

We will see if genomics lives up to its promise, of course. As another scientist, Neils Bohr, said: 'Prediction is difficult, especially about the future.' Even the exquisite DNA translation process sometimes gets it wrong and proteins end up with the wrong amino acids, impairing their function. Indeed the majority of DNA itself is regarded as 'junk', because it seems to have no function. All of this all sounds a bit like computer code and its creation, another systematic human process.

I have been fascinated by interface between man and machine for more than 30 years. Now it seems more alluring than ever.

Last week BBC's Click programme showed (6m 38s) a one year old iPad user confused by a print magazine where she couldn't 'flick' the pages: a sign of the times.

A few years ago there was a kerfuffle in healthcare IT. A study at the Childrens Hospital of Pittsburgh concluded that mortality rates had increased with the implementation of Computerised Physician Order Entry System (CPOE). Despite being rebutted almost immediately after publication, the study gained wide credibility. It was still being quoted without qualification by a prominent academic at a UK healthcare IT conference a couple of years ago.

• The 2007 rankings indicate an overall worsening of privacy protection across the world, reflecting an increase in surveillance and a declining performance o privacy safeguards.
• Concern over immigration and border control dominated the world agenda in 2007. Countries have moved swiftly to implement database, identity and fingerprinting systems, often without regard to the privacy implications for their own citizens
• The 2007 rankings show an increasing trend amongst governments to archive data on the geographic, communications and financial records of all their citizens and residents. This trend leads to the conclusion that all citizens, regardless of legal status, are under suspicion.
• The privacy trends have been fueled by the emergence of a profitable surveillance industry dominated by global IT companies and the creation of numerous international treaties that frequently operate outside judicial or democratic processes.
• Despite political shifts in the US Congress, surveillance initiatives in the US continue to expand, affecting visitors and citizens alike.
• Surveillance initiatives initiated by Brussels have caused a substantial decline in privacy across Europe, eroding protections even in those countries that have shown a traditionally high regard for privacy.
• The privacy performance of older democracies in Europe is generally failing, while the performance of newer democracies is becoming generally stronger.
• The lowest ranking countries in the survey continue to be Malaysia, Russia and China. The highest-ranking countries in 2007 are Greece, Romania and Canada.
• The 2006 leader, Germany, slipped significantly in the 2007 rankings, dropping from 1st to 7th place behind Portugal and Slovenia.
• In terms of statutory protections and privacy enforcement, the US is the worst ranking country in the democratic world. In terms of overall privacy protection the United States has performed very poorly, being out-ranked by both India and the Philippines and falling into the "black" category, denoting endemic surveillance.
• The worst ranking EU country is the United Kingdom, which again fell into the "black" category along with Russia and Singapore. However for the first time Scotland has been given its own ranking score and performed significantly better than England & Wales.
• Argentina scored higher than 18 of the 27 EU countries.
• Australia ranks higher than Slovakia but lower than South Africa and New Zealand.

1. Starting today I have taken on the position of President of the Canadian Health Information Technology Trade Association (CHITTA), the health care division of the Information Technology Association of Canada (ITAC). This will get me back into the game following my year long sabbatical studying all dimensions of eHealth risk.
2. The Waterloo Institute for Health Informatics Research has posted the next series of eHealthRisk Workshops. New this year is the eHealth Information Security Workshop whose inaugural run will be from March 26 to 28, 2008 at the University of Waterloo.

Self-care in e-space and the need to Impress

Kim MI, Johnson KB. Personal Health Records: Evaluation of Functionality and Utility. Journal of the American Medical Informatics Association. 2002. Mar-Apr; 9(2):171-180. Selected for inclusion in the IMIA 2003 Yearbook of Medical Informatics. 

Kim MI, Johnson KB. Personal Health Records: Evaluation of Functionality and Utility. Journal of the American Medical Informatics Association. 2002. Mar-Apr; 9(2):171-180. Selected for inclusion in the IMIA 2003 Yearbook of Medical Informatics. 

I just have three things to say. First of all, the word is pronounced PRE-scription not PER-scription.

Secondly, if we’re talking medicinal, you want to know something that is broken in the health care system? I’ll tell you: pharmacies. What value does a pharmacist add? None. They can be immediately replaced by vending machines and websites (thx, Zach.) I can read my own labels, thank you very much.

Finally, why are many non-addictive medications by prescription anyway? Here’s an example: ibuprofen. You can buy OTC ibuprofen, and they usually come in 200mg tablets. 200mg doesn’t do anything useful, so what do people do? They take 4-8 of them. If you go to a doctor with a bad headache, they’ll prescribe you ibuprofen in 800mg tablets. I’m sorry Mom, but that’s retarded. Ibuprofen doesn’t need to be by prescription. Here’s another: Liptor. Lipitor is used for reducing cholesterol. “But wait,” Mr. Wily protests, “what if a user bought Lipitor and decided to take more than the label suggested? That would be bad.” Indeed, but the side effects of Lipitor are headache and muscle soreness, hardly cause for alarm. On the other hand, too much of lots of OTC drugs can be harmful as well. For example, excessive Tylenol can hurt your liver, but Tylenol isn’t by prescription. Why?

While I’m at it, doctors themselves are close to obsolete. The Internet is making elite bearers of information unnecessary. When I last went to the doctor for a checkup, he GOOGLED a symptom during our visit. GOOGLED. I can google. Thanks for charging me for your web surfing.

That’s all.

What’s wrong with Medicine today?

Let’s design the most inefficient, error-prone, hackable system for transmitting medical information.

We’ll start by having persons with notorious handwriting, doctors, scribble in code onto a piece of paper.

Then, the afflicted person (the patient) jams that paper into their pants’ pocket and carries it down to a non-doctor (a pharmacy tech), who attempts to decipher the information and enter it into the computer.

If it’s a new pharmacy or a new doctor, they have NO IDEA what you’ve been prescribed before, or what you’re currently taking.

Why, why, why?

Actor George Clooney was admitted last month to the the Palisades Medical Center after a motorcycle accident. The temptation to look at Mr. Clooney’s medical file was just too much a couple dozen unauthorized employees to withstand. 27 people looked. 27 people are now suspended for a month without pay according to CNN.com. Sadly, the impetus for the investigation was not that they viewed Clooney’s records without cause, but that they leaked information to the press… HIPAA, it’s got (some) teeth now.

After close to two years of effort (see here) the Healthcare IT Stack Exchange Site is closing for good. HealthCare IT is closing:

it simply does not appear that this topic has a strong enough following on our network to support the site long-term

That says it all.

Healthy Architectures – Using CQRS and Event Sourcing for Electronic Medical Records presents a couple of interesting patterns for the management of healthcare data. The two patterns are:

• Command Query Responsibility Segregation (CQRS)
• Event Sourcing (ES)

Here’s another article that provides further clarification on the CQRS pattern and how it compares to ES and Task-Based UIs: CQRS, Task Based UIs, Event Sourcing agh!

These are high level design patterns that result in non-traditional and more complex system architectures when implemented.  The healthcare domain is complex and alternate approaches for providing robust solutions are worth consideration.

My last discussion of Off-The-Shelf software validation only considered the high-level regulatory requirements.  What I want to do now is dig deeper into the strategies for answering question #5:

How do you know it works?

This is the tough one. The other questions are important, but relative to #5, answering them is pretty easy.  How to answer this question (i.e. accomplish this validation) is the source of a lot of confusion.

There are many business and technical considerations that go into the decision to use OTS or SOUP software as part of a medical device. Articles and books are available that include guidance and general OTS validation approaches. e.g. Off-the-Shelf Software: A Broader Picture (warning PDF) is very informative in this regard:

• Define business’ use of the system, ideally including use cases and explicit clarification of in-scope and out-of-scope functionality
• Determine validation deliverables set based on system type, system risk, project scope, and degree of system modification
• Review existing vendor system and validation documentation
• Devise strategy for validation that leverages vendor documentation/systems as applicable
• Create applicable system requirements specification and design documentation
• Generate requirements-traceable validation protocol and execute validation
• Put in place system use, administration, and maintenance procedures to ensure the system is used as intended and remains in a validated state

This is great stuff, but unfortunately it does not help you answer question #5 for a particular type of software. That’s what I want to try to do here.

OTS really implies Commercial off-the-shelf (COTS) software. The “commercial” component is important because it presumes that the software in question is a purchased product (typically in a “shrink-wrapped” package) that is designed, developed, and supported by a real company.  You can presumably find out what design controls and quality systems are in place for the production of their software and incorporate these findings into your own OTS validation.  If not, then the product is essentially SOUP (keep reading).

Contrast OTS with Software of Unknown Provenance (SOUP).  It is very unlikely that you can determine how this software was developed, so it’s up to you to validate that it does what it’s supposed to do.  In some instances this may be legacy custom software, but these days it probably means the integration of an open source program or library into your product.

This following list is by no means complete. It is only meant to provide some typical software categories and the strategies used for validating them.  Some notes:

• I’ve included a Hazard Analysis section in each category because the amount of validation necessary is dependent on the level of concern.
• The example requirements are not comprehensive. I just wanted to give you a flavor for what is expected.
• Always remember, requirements must be testable.  The test protocol has to include a pass/fail criteria for each requirement. This is QA 101, but is often forgotten.
• I have not included any example test protocol steps or reports.  If you’re going to continue reading, you probably don’t need help in that area.

Operating Systems

Examples:

• Windows XP SP3
• Windows 7 32-bit and 64-bit
• Red Hat Linux

Approach:

1. Hazard Analysis: Do a full  assessment of the risks associated with each OS.
• Pay particular attention to the hazards associated with device and device driver interactions.
• List all hazard mitigations.
• Provide a residual Level of Concern (LOC) assessment after mitigation — hopefully this will be negligible.
• If the residual LOC is major, then Special Documentation can still be provided to justify its use.
2. Use your full product verification as proof that the OS meets the OTS requirements. This has validity since your product will probably only be using a small subset of the full capabilities of the OS.  All of the other functionality that the OS provides would be out of scope for your product.
3. This means that a complete re-validation of your product is required for any OS updates.
4. There is no test protocol or report with this approach. The OS is considered validated when the product verification has been successfully completed.

Compilers

Examples:

• Visual Studio .NET 2010  (C# or C++)

Integrated Libraries

Examples:

• Log4Net (Log4J) — Log generation
• Hibernate/NHibernate  — Database Object/Relational Mapping

Version Control Systems

Examples:

• Subversion (+TortoiseSVN)
• Git (+TortoiseGit)

Issue Tracking Tools

Examples:

• Trac
• Jira
• FogBugz

Validation is a lot of work but is necessary to ensure that all of the tools and components used in the development of medical device software meet their intended functionality.

The P Wave P waves are caused by atrial depolarization. In normal sinus rhythm, the SA node acts as the pacemaker. The electrical impulse from the SA node spreads over the right and left atria to cause atrial depolarization. The P wave contour is usually smooth, entirely positive and of uniform size. The P wave duration is normally less than 0.12 sec and the amplitude is normally less than 0.25 mV. A negative P-wave can indicate depolarization arising from the AV node.

Note that the P wave corresponds to electrical impulses not mechanical atria contraction. Atrial contraction begins at about the middle of the P wave and continues during the PR segment. The PR Segment PR segment is the portion on the ECG wave from the end of the P wave to the beginning of the QRS complex, lasting about 0.1 seconds. The PR segment corresponds to the time between the end of atrial depolarization to the onset of ventricular depolarization. The PR segment is an isoelectric segment, that is, no wave or deflection is recorded. During the PR segment, the impulse travels from the AV node through the conducting tissue (bundle branches, and Purkinje fibers) towards the ventricles. Most of the delay in the PR segment occurs in the AV node. Although the PR segment is isoelectric, the atrial are actually contracting, filling the ventricles before ventricular systole.

The QRS Complex In normal sinus rhythm, each P wave is followed by a QRS complex. The QRS complex represents the time it takes for depolarization of the ventricles. The Q wave is not always present. The R wave is the point when half of the ventricular myocardium has been depolarized. The normal QRS duration range is from 0.04 sec to 0.12 sec measured from the initial deflection of the QRS from the isoelectric line to the end of the QRS complex.

Normal ventricular depolarization requires normal function of the right and left bundle branches. A block in either the right or left bundle branch delays depolarization of the ventricles, resulting in a prolonged QRS duration.

The ST Segment The ST segment represents the period from the end of ventricular depolarization to the beginning of ventricular repolarization. The ST segment lies between the end of the QRS complex and the initial deflection of the T-wave and is normally isoelectric. Although the ST segment is isoelectric, the ventricules are actually contracting.

The T Wave The T wave corresponds to the rapid ventricular repolarization. The wave is normally rounded and positive.

1. Every Medical Practice Needs a CIO
2. AMA publishes a FAQ on encryption
3. Six Healthcare Data Breaches That Might Make Security Pros Sick

1. Every Medical Practice Needs a CIO
2. Network Costs of an EMR Implementation
3. The dangers of cloud computing

1. Every Medical Practice Needs a CIO
2. HIPAA Security Rule Implementation
3. HIPAA Security Rule Risk Analysis and Management

Recently, I was in discussion with couple of my friends who are Clinicians & the topic of ‘healthcare IT in India’ popped up as it has been my habit to raise this topic in such forums to get ideas and feedback. This time to my surprise everyone around the table were really interested in this topic! which was not so in some of my earlier discussions with them. Interesting, I started probing further and I could clearly make out the increased awareness of Healthcare IT and its benefits in their practice.

Some of them had started using some or the other IT products and were inching towards more advanced solutions. I am just sharing 6 excerpts from the discussion.

Computer education:  As usual the team felt that the inhibition for adopting IT systems is largely because of lack of computer education in medical fraternity however, they also felt that the newer generation is embracing it fast & cross industry partnerships could help in improving the situation.

System usability: No surprise!, usability was a major concern. You blame it to either their experience level in system usage or bad designs of the products in either case it was found to be an issue which is bothering them.  May be system designers should do bit more user analysis and come out with creative usable products which would provide them easy to use UIs.

Solutions in the market: Interesting to find that they still feel that they are not many products in the market which are path breaking and fit their purpose, there are many big players offering their global products with little variations which are actually too far from what they need and new startups seems to be underestimating their needs.

Affordability: No doubt it is a price sensitive market, They feel it is little expensive to go for IT solutions however, in my opinion certainly people have realized what IT can do to their practice but there is a need to justify the quantum of value addition & also providers should think of different billing models to increase adoption.

Pervasiveness: It’s not a desktop bound job! They need solutions which are pervasive enough to move around with them and assist as and when they want, may be mobile or tablet based solutions could be an answer for this.

Fear of losing data: Somewhere in the corner they also expressed concern towards data and its maintenance. The fear is quite apparent because they are used to records and reports which are in more tangible physical forms but I am sure that confidence building and demonstration of  technology usage in other industries and also in healthcare in other countries would bring in more confidence.

These points may be views from a small group of people but sure points to look further. Please feel free to add your feedback and experience in below comment box.

The Arab Health Exhibition & Congress is the largest event of its kind in the Middle East. Now in its 37th year, Arab Health provides an unrivalled platform for the world’s leading manufacturers, wholesalers and distributors to meet the medical and scientific community from the Middle East and beyond.

Promising to be the most successful year yet, Arab Health is truly at the heart of global healthcare. With the Middle East healthcare industry worth an estimated $80 billion per year, there is simply no other event for buyers, suppliers, manufacturers and distributors to meet and do business.

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Over the past decade, I’ve seen a number of studies asking people whom they trust among various health care stakeholders. Nurses, pharmacists, and doctors always come out at the top.  Beyond that:

• Trust of hospitals tends to be high (60–80%)
• Trust of health plans is at the bottom of the heap (10–20%)

Is this written in stone for the future? I don’t think so…and the dynamics for change are in motion.  Please read on.

Here’s the emerging picture I’m seeing:

• Hospitals are dragging their feet in connecting you with your electronic health information.
• Health plans are highly motivated to connect you with your health information. (more…)

One of the biggest concerns about ACOs has been their potential to enable market consolidation— that by uniting health care providers the ACO gains market clout and ability to charge higher prices.

While this is a legitimate concern about ACOs, so far it’s not playing out.

Why?

(more…)

I’m surprised and intrigued by Medicare’s announcement of 27 new Shared Savings model ACOs.

Surprised

I had been anticipating this announcement as a defining moment for Medicare’s thrust into accountable care. My expectations had been that we would see either:

Boom — a big splash of new Medicare shared savings ACOs announced, including big name hospitals and medical groups that were starting large scale ACOs, perhaps with hundreds of thousands of patients.

Bust — no one showed up at the party. Providers would have concluded that Medicare ACOs were too risky, bureaucratic, and high effort.

Intrigued

What we got is something in the middle: (more…)

NIST would like suggestions from the public regarding how federal agencies should be involved in the standardization system. Standardization areas include but are not limited to: smart grid, health information technology, cybersecurity, emergency communications interoperability, radioactivity detector and radiation monitors. Public comments are due by February 7, 2011.

Read the full story:
http://www.healthcareitnews.com/news/nist-seeks-input-government-involvement-standardization

By yesterday, two states had already sent out checks to Medicaid participants just two days after registration for the program had opened. The checks came from Kentucky and Oklahoma, with many other states soon to follow. There has been some skepticism regarding how smoothly the meaningful use incentives programs will go. Maybe these recent events will put people more at ease.

Read the full story:
http://www.healthdatamanagement.com/news/meaningful-use-ehr-incentive-check-medicaid-41699-1.html?ET=healthdatamanagement:e1596:159225a:&st=email&utm_source=editorial&utm_medium=email&utm_campaign=HDM_Daily_010611

Experts are already making disheartening predictions for health information privacy in 2011, such as increased fines, data breaches, regulations, penalties, etc.

What are your thoughts on the issue?

Read the full story:
http://www.healthcareitnews.com/news/experts-name-top-7-trends-health-information-privacy-2011

From the MIT press release

Researchers at MIT and two Boston hospitals provide early evidence that a simple, unobtrusive wrist sensor could gauge the severity of epileptic seizures as accurately as electroencephalograms (EEGs) do — but without the ungainly scalp electrodes and electrical leads. The device could make it possible to collect clinically useful data from epilepsy patients as they go about their daily lives, rather than requiring them to come to the hospital for observation. And if early results are borne out, it could even alert patients when their seizures are severe enough that they need to seek immediate medical attention.

Rosalind Picard, a professor of media arts and sciences at MIT, and her group originally designed the sensors to gauge the emotional states of children with autism, whose outward behavior can be at odds with what they’re feeling. The sensor measures the electrical conductance of the skin, an indicator of the state of the sympathetic nervous system, which controls the human fight-or-flight response.

In a study conducted at Children’s Hospital Boston, the research team — Picard, her student Ming-Zher Poh, neurologist Tobias Loddenkemper and four colleagues from MIT, Children’s Hospital and Brigham and Women’s Hospital — discovered that the higher a patient’s skin conductance during a seizure, the longer it took for the patient’s brain to resume the neural oscillations known as brain waves, which EEG measures.

At least one clinical study has shown a correlation between the duration of brain-wave suppression after seizures and the incidence of sudden unexplained death in epilepsy (SUDEP), a condition that claims thousands of lives each year in the United States alone. With SUDEP, death can occur hours after a seizure.

Currently, patients might use a range of criteria to determine whether a seizure is severe enough to warrant immediate medical attention. One of them is duration. But during the study at Children’s Hospital, Picard says, “what we found was that this severity measure had nothing to do with the length of the seizure.” Ultimately, data from wrist sensors could provide crucial information to patients deciding whether to roll over and go back to sleep or get to the emergency room.

Read the full press release

(From the CFP website)

Sensors, such as wireless EEG caps, that provide us with information about the brain activity are becoming available for use outside the medical domain. As in the case of physiological sensors information derived from these sensors can be used – as an information source for interpreting the user’s activity and intentions. For example, a user can use his or her brain activity to issue commands by using motor imagery. But this control-oriented interaction is unreliable and inefficient compared to other available interaction modalities. Moreover a user needs to behave as almost paralyzed (sit completely still) to generate artifact-free brain activity which can be recognized by the Brain-Computer Interface (BCI).

Of course BCI systems are improving in various ways; improved sensors, better recognition techniques, software that is more usable, natural, and context aware, hybridization with physiological sensors and other communication systems. New applications arise at the horizon and are explored, such as motor recovery and entertainment. Testing and validation with target users in home settings is becoming more common. These and other developments are making BCIs increasingly practical for conventional users (persons with severe motor disabilities) as well as non-disabled users. But despite this progress BCIs remain, as a control interface, quite limited in real world settings. BCIs are slow and unreliable, particularly over extended periods with target users. BCIs require expert assistance in many ways; a typical end user today needs help to identify, buy, setup, configure, maintain, repair and upgrade the BCI. User-centered design is underappreciated, with BCIs meeting the goals and abilities of the designer rather than user. Integration in the daily lives of people is just beginning. One of the reasons why this integration is problematic is due to view point of BCI as control device; mainly due to the origin of BCI as a control mechanism for severely physical disabled people.

In this challenge (organised within the framework of the Call for Challenges at ICMI 2012), we propose to change this view point and therefore consider BCI as an intelligent sensor, similar to a microphone or camera, which can be used in multimodal interaction. A typical example is the use of BCI in sonification of brain signals is the exposition Staalhemel created by Christoph de Boeck. Staalhemel is an interactive installation with 80 steel segments suspended over the visitor’s head as he walks through the space. Tiny hammers tap rhythmic patterns on the steel plates, activated by the brainwaves of the visitor who wears a portable BCI (EEG scanner). Thus, visitors are directly interacting with their surroundings, in this case a artistic installation.

The main challenges to research and develop BCIs as intelligent sensors include but are not limited to:

• How could BCIs as intelligent sensors be integrated in multimodal HCI, HRI and HHI applications alongside other modes of input control?
• What constitutes appropriate categories of adaptation (to challenge, to help, to promote positive emotion) in response to physiological data?
• What are the added benefits of this approach with respect to user experience of HCI, HRI and HHI with respect to performance, safety and health?
• How to present the state of the user in the context of HCI or HRI (representation to a machine) compared to HHI (representation to the self or another person)?
• How to design systems that promote trust in the system and protect the privacy of the user?
• What constitutes opportune support for BCI based intelligent sensor? In other words, how can the interface adapt to the user information such that the user feels supported rather than distracted?
• What is the user experience of HCI, HRI and HHI enhanced through BCIs as intelligent sensors?
• What are the ethical, legal and societal implications of such technologies? And how can we address these issues timely?

We solicit papers, demonstrators, videos or design descriptions of possible demonstrators that address the above challenges. Demonstrators and videos should be accompanied by a paper explaining the design. Descriptions of possible demonstrators can be presented through a poster.
Accepted papers will be included in the ICMI conference proceedings, which will be published by ACM as part of their series of International Conference Proceedings. As such the ICMI proceedings will have an ISBN number assigned to it and all papers will have a unique DOI and URL assigned to them. Moreover, all accepted papers will be included in the ACM digital library.

Deadline for submission: June 15, 2012
Notification of acceptance: July 7, 2012
Final paper: August 15, 2102

Researchers at Federal Institute of Technology in Lausanne, Switzerland (EPFL), have successfully demonstrated a robot controlled by the mind of a partially quadriplegic patient in a hospital 62 miles away. The EPFL brain-computer interface system does not require invasive neural implants in the brain, since it is based on a special EEG cap fitted with electrodes that record the patient’s neural signals. The task of the patient is to imagine moving his paralyzed fingers, and this input is than translated by the BCI system into command for the robot.

Having written a chapter on eResearch for a book on Health Informatics, I decided to make a video which will be used by the editor, Bob Hoyt, in an eBook edition to come out soon. Both the video and the chapter emphasize the progress that has been made in informatics tools to support every phase of clinical research.

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UX has always been one of my favorite topics. So often ignored in application development, usability is key to the success of any website or app. Fortunately, there is  a Usability Professionals Association dedicated to the concept.  A recent presentation at the Northeast Ohio Chapter focused on the evaluation of the usability of the Cleveland Clinic website. This comprehensive review lead to the development of standards for the website based on user input.

Check out the presentation by Kaitlan Chu:

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Last week I was fortunate to attend TEDx Maastricht in person for the second year in a row. There were several great talks, all inspiring and some surprising. The beginning and end represented innovations in care of very different types. Beginning with a demonstration of FaceTalk, a live demo of an interdisciplinary consultation between 3 physicians on 3 continents sharing CT scans and more in real time. The final presentation of a video of interviews with young adult cancer survivors even facing death with courage. Patients were certainly invited and had an impact on the overall tone of the conference. One example was  Clarissa Silva who said about her recovery from mental illness, “Courage is being afraid but doing it anyway.”

A big hit was Paul Levy who talked about healthcare and soccer (football). One choice quote is advice to a girl from the team of 11 year olds he coaches: “Think about what you are going to with the ball before it arrives.” This certainly applies to future thinking in the dynamic health care environment. Check out his book, Goal Play. Then there was Paul Grundy from IBM made the comparison of physicians as the master builders of European cathedrals, trying keeping everything in their head as knowledge explodes. This leads to his conclusion of Smarter healthcare by smarter use of data.

Much anticipated was Roni Zieger, formerly of Google Health presented on Embrace the Patient Story. He talked about his own experience with a medical problem but then discussed how patients can become experts in their own care and therefore experts with others. His collaboration with Lucien Engelen, MyHealthStory, was a beginning down his new path. Now he is planning with Gilles Frydman of ACOR a new venture called Impatient Health, because they and many patients are impatient to participate fully in not only helping others as Patient Experts but also as active participants in research.

A great surprise was the introduction to the documentary “The Waiting Room.” Afterwards I had the opportunity to view the film – it is a heart-wrenching view of the real struggles of the uninsured in the US using the emergency room for primary care. I hope with the producers that the film will have a role in the health care reform debate.

Thanks to Lucien Engelen and Corine Jansen of the Radboud Reshape and Innovation Center for making this event possible. Looking forward to The Future of Health 2013.

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I spend a good deal of time with clients these days who are trying to connect web services, implement service oriented architecture (SOA), and moving to the cloud. All these requirements are focused on integration of multiple, sometimes legacy sometimes modern, systems but most of them still require lots of HL7 interfacing. Some of my clients start their integration efforts hoping that there is something better or more modern than HL7 but the truth is that HL7 and interfacing remains the backbone of health system integration. Choosing an integration tool is time consuming so I reached out to Craig Cunic, the Product Director of Interface Engine Team at Iatric Systems, to get some advice on how to choose an interfacing engine. Iatric has been solving complex health IT problems for a while so it’s worth following’s Craig’s advice on the Dos and Don’ts for Interface Engine Consideration. Here’s what he said:

It has been suggested that due to the advent of web services, Service-Oriented Architecture (SOA), and cloud computing, interface engines no longer serve as the proper tool for system integration. Is the interface engine dead? Yes, it is, if the interface engine does not have the necessary feature-set to support the growing number of data standards and if it can’t exchange data with today’s diverse healthcare systems and devices.

Today’s interface engine is an advanced integration engine.

The interface engine is not dead. Today’s interface engine is alive and well…and it is one with advanced features that turn it into a mighty integration engine. It is one that has extensive security and privacy features and the scalability to grow with your increased interface needs. Today’s interface engine also integrates clinical portals and medical devices, achieves other complex integration situations and supports Meaningful Use mandates. And, an advanced integration engine is easy on your IT budget: it helps control the budget because there are no ongoing interface costs.

If you are considering upgrading your current interface engine to an advanced integration engine or want to move away from point-to-point interfaces, here are the dos and don’ts to consider when researching and evaluating different integration engines:

• Do consider engines built on modern platforms such as .NET or J2EE. These will have a leg up on the competition in terms of being able to fulfill many of the requirements mentioned above.
• Don’t overlook the potential barriers in data sharing. Look for an engine that can simplify these types of communications: direct to database (ADBC, OLE, DB, Oracle and SQL), transfer types MLLP, TCP/IP, folder shares FTP (SFTP and FTPS) and SOAP.
• Don’t select any engine that is built on outdated technology. Look for engines built on advanced architectures to ensure scalability and extensibility and to support new formats and new demands as they arise.
• Do look beyond the engine’s interface capabilities – look into its ability to monitor all activity in real time and deliver exception notifications automatically. Engines using a visual IDE are best. Monitoring performance and sending problem alerts are critical for minimizing downtime, which has a negative effect on healthcare.
• Do analyze the vendor that is offering the solution and evaluate the level of customization that the vendor provides to meet your specific security needs. Also look at how much support the vendor provides in terms of minimizing IT effort at your organization.
• Do make sure the engine supports all major standard messaging data formats (delimited, fixed length, HL7 2.x and XML).
• Do consider the time that must be dedicated to set up each interface, train users, record updates and generate useful reports.
• Don’t forget that modern systems need to integrate using scripting languages such as PHP, Ruby, Perl, and Python. While .NET and J2EE are kinds of the enterprise world, scripting and glue languages are the yeoman of the integration world.

Interface engines are a core element in today’s healthcare environment, and are a requirement to achieve interoperability and meet Meaningful Use. The interface engine you choose should not only streamline your healthcare organization’s ability to share medical data with providers, patients and the community, but also minimize the IT efforts necessary to accomplish this sharing.

Like many of you, I made the annual pilgrimage to the HIMSS Conference last month but I didn’t write much publicly about it (I mostly wrote private analyst reports for specific clients). There’s so much noise at such a big conference that I like writing about HIMSS gatherings after a little time has passed and I can discuss the market landscape with vendors outside the craziness of the conference. Here’s what I learned while I was in Vegas and my takeaways for the rest of the year.

Major developments in Health IT for the rest of 2012

It was discussed a lot in the educational sessions and vendors didn’t talk about it much, but the new realities of complex business models (like PCMH and ACOs) mean that standardization of clinical workflows won’t really be possible for a while. The open secret is that most EHRs are not up to the task of handling the complexities of new business models, though. I believe the big shift to cloud computing and mHealth will mean that smaller and more nimble “apps” (both web based and mobile) will start to shoulder more of the burdens that are being thrown in by new business models. When you add more services (like smaller cloud apps and mHealth apps) more and more orchestration across services and apps is necessary (not larger apps).  The common wisdom is that there will be fewer EHRs as consolidation occurs but that’s not going to happen – interfacing, interoperability, and real service based platforms will be created that can handle the next level of more sophisticated requirements. We’ll move from basic record keeping and document management to more refined patient management, patient engagement, social electronic health records, and collaboration-driven software. The older vendors will start to hear the collaboration siren songs and jump on board pretty quickly.

How the role of EHRs will change

The best EMRs will be those that become the central “dashboard” around the most complex healthcare workflows and begin to really become “coordinators” amongst multiple systems instead of a monolithic application. Clinicians really need to understand that their EHRs need to be their patients’ social health record and relationship management system and not just their chart management system. The role of the EMR must and will change to being the patient-centric collaboration and engagement driver and will just happen to store documents, charts, and MU records as a byproduct. When retrospective documentation becomes a byproduct of more collaborative care systems then we all win.

Developments in coordinated care

I’m not sold on coordinated care technologies “writ large” – the problem is that the government and vendors are making it sound as if this is the first time care has been coordinated. In reality, care has always been (at least minimally) coordinated in the physical realm – e.g. referrals have been used to coordinate care for decades. The level of technology coordination and the amount of measurements that have always been tough to define, implement, and secure continue to remain just as difficult. The good news is that we’re all in agreement that we need to coordinate care; the bad news is that we don’t really know what that means but we’re seeing vendors say they have systems that support it (which means they’re either misleading customers or they don’t know what they’re talking about). Care coordination is about clinical integration as opposed to record sharing and we have a long way to go to really implement seamless coordination even though we have the basic technologies available to do so now (the basic technologies are social media, e-mail, and the web, not EHRs).

Security challenges need more thought and attention

The privacy rules are getting tighter and tighter but the relationships between care providers are expanding farther and deeper. For example, now all IT vendors that used to be just contractors are in some respects HIPAA business associates – there are tons of implications for vendors that they’ve not started to grasp yet. Also, think about PCMH and ACOs – they create new business relationships and care models that create significant headaches for security professionals. The healthcare world, while it’s getting more complicated, wants to get more secure at the time and it’s not reasonable to think you can make business models more complex and at the same time have more security – something’s going to give.

Don’t think HIPAA means security

At HIMSS people kept tying security and HIPAA – as I reminded my readers last year, HIPAA is not really a security standard – it’s a compliance framework and provides general guidance. I continue to recommend that organizations expand their focus from HIPAA when constructing their healthcare security policy, and model their documents off of NIST (National Institute of Standards and Technology) and other resources. NIST actually provides measures, security controls, risk frameworks, and standards that can be followed. If you follow general NIST guidelines and have really secure systems based on NIST suggestions then meeting HIPAA regulations are a piece of cake.

Biggest HIT-related and healthcare changes that physicians should prepare for

HIPAA 5010, ICD-10, and MU Phase 1/2 will keep everyone busy; start to worry about converting all your vendors into HIPAA business associates and become experts at data integration and connecting multiple software systems. Forget your focus on vertical (e.g. EHR) applications and start to focus on best of breed, smaller apps, and integrating multiple apps.

Role of payers in setting technology solution standards

The role of payers in setting technology standards is growing and will be significant and consequential – in fact, without the payers driving the train nothing will really happen. Now that Medicare has taken the lead, the big payers will be right behind. The beneficiaries of ACOs are likely to first be payers, not just patients. I’ll be writing more about this in the future.

Now that we’ve had a month to think about it, what is your follow up advice from the HIMSS’12 Conference? Drop me a note below.

I was recently interviewed for a nice article on why and how private physician practices should push for new technologies. Andrea Downing Peck did a pretty good job putting together a collage of views from me and some of my well known colleagues online: Mary Pat Whaley, David Henriksen, Dr. Jaan Sidorov, Shari Crooker, Rosemarie Nelson, David Harvey, David Williams.

Here are some of my favorite quotes (taken directly from the article):

• Mary Pat Whaley: "Patients are saying, ‘If I can’t register for your practice online or ask for an appointment or get a prescription online, I really don’t want to work with you. If the convenience isn’t there, [they] don’t have time in [their] lives for a physician who is not going to offer these things."
• About Data safety remaining a concern with cloud computing, Dr. Sidorov say: "Is all that patient information really secure being stored on some server in Singapore? Will it be easier for some hacker to [break] into that particular database? Maybe I don’t know. It’s probably better than storing patient information on a local server in a closet next to a water heater in a typical physician’s office."
• David E. Williams: "The physician’s office is one of the last places you can go into where, if you’re Rip Van Winkle and have been asleep since the 1950s, you’ll feel comfortable there seeing all the colored tab folders with the patient records and so on.”
• Shahid Shah: “As long as we have insurance, any PCP, especially those dealing with the elderly, are probably safe not being super advanced," he says. "But if you’re a practice that wants to go after the high-end, high-value profitability patient, you’re signing your death warrant if you are not [technologically] advanced.”
• Dr. Warwick Charlton suggests modular technology solutions: "If your system is monolithic…it’s very hard to get that incremental gain that dedicated modular systems can get. Over the long run, it’s a less scalable, less technologically adaptable answer."

Probably the single best advice came in the paragraph below (make sure to get the integration with advanced functionality):

Describing the practice’s first go-round with an EHR as "disastrous because it was so complicated and expensive," McMahon has made paramount selecting the right EHR/PM this time around. Her wish list for a cloud-based integrated EHR/PM system makes ease of use a priority along with features such as voice dictation, e-prescribing, integration with scanners and fax machines, interfaces with existing medical equipment, and a patient portal that offers appointment reminders and bill payment options.

When looking for integrated solutions, though, be sure to heed Dr. Charlton’s advice and go modular and not monolithic. Over the long run, no single solution will fit your bill so you need to prepared to become an integration specialist.

Any physician would be happy to get maximum reimbursements for the service that he/she rendered. But, the present circumstances in the United States demands physicians not only be great healthcare professionals, but also be smart enough to earn maximum reimbursements in medical billing. Now, getting maximum payouts is in the hands of the physician and not just the insurance carrier. Let me list the prime factors that can affect maximum reimbursements for your service.

1. Non-participation with insurance carriers: It is inevitable for physicians to get credentialed or become participating with all major insurance carriers. Non-participation with medicare and Medicaid leads to denial whereas other commercial carriers pay lesser than you deserve for the service that you rendered. So, choose physician credentialing for enhanced payout.

1. Clinical documentation: In most of the cases of denials or underpayment, improper clinical documentation is a reason.  Improper clinical documentation with errors or insufficient documentation can be a cause for processing errors, particularly in medical billing and coding, affecting reimbursements.

1. 3. Processing errors: The most important and the difficult to avoid is the processing errors. This includes all errors in processing starting with data entry till the processing of the claims, including patient demographics, coding, charge entry etc.,  It is essential to keep track of the processing errors and find ways to eliminate/ reduce such errors that can affect payment.

1. 4. Healthcare implementations: The U.S. healthcare industry is facing the greatest challenges in the form of healthcare implementations. The approaching deadlines and the efforts required to implement the same is scaring physicians across the United States. Even then, it is essential to follow the suggestions put forth by the government and allied bodies in order to improve the quality of healthcare.  The CMS encourages timely healthcare implementations by providing incentives and penalizing for not following the schedule. Therefore, physicians have to be cautious in making necessary Implementations on time to avoid penalty.

1. 5. Timely Filing Limit: TFL is a valid point that lays emphasis on timely filing of the claims to insurance carriers. Though the TFL varies for different insurance carriers, failing to submit claims before the TFL will result in the denial of claims by all insurance carriers.

1. Failing to appeal for claims: If the genuine claims are denied or underpaid, it is essential to appeal for reconsideration, which provides the possibility of getting the claims accepted or paid better, based on the appeal. Failing to do so is a loss to the practice, affecting the reimbursements.

Ensure that you meet the terms with the above mentioned points to assure maximum reimbursements and improved collections in medical billing.  It is also essential that physicians periodically look out for any updates from the government and allied organizations that can affect reimbursements.

With the medical billing and coding industry evolving and changing at an unprecedented rate, the focus has shifted from simple (paper?) to complex and complete documentation – be it on the clinical or process side. As and when new changes get announced, there is more and more emphasis on the necessity for proper documentation.

Many consider documentation a pain and fail to understand the importance of it.  It may not be required immediately, but it can be safely presumed that it would come in handy at a future point in time. Let me highlight some instances where proper documentation is not only an option but a must-have.

Insurance Auditing:

The most frightening nightmare that a practice can have is – the insurance audit. With the advent of the RACs, MICs and ZPICs, every Healthcare entity is at risk of being audited and penalized.  The only solution that can alleviate this problem a little is by having proper documentation.  Also, the Appeals data of the past 2 years show that Healthcare professionals with complete and proper documentation had a very high success rate when they appeal the ruling made by the Auditors.  It certainly pays to be methodical and careful with documentation instead of losing both past and potential future revenues to Audits.

Accurate medical billing and coding:

Documentation is the key to accurate billing and coding.  Many entities follow the simple rule – ‘If it is not documented, it cannot be Coded or Billed’.  This policy is followed not only to promote ‘Best Practices’ in Billing, but also to avoid later complications during Audits. Any omission of details while documenting can lead to under payments and/or even denials.  Many Providers realize the extent of revenue loss incurred by them due to poor documentation, only when they go through an audit of their past claims.  Moreover, ICD-10 being much more detailed in its Code-sets, demands clinical documentation to be precise in order to get accurate payments.

Process Improvement:

Process improvement and re-engineering are the key to evolve with the changing times for any process, including medical billing and coding. Failure to improve or re-engineer processes in accordance to new guidelines and rules, results in denials and underpayments which ultimately lead to the demise of the entity.  There have been several instances where Healthcare institutions declared bankruptcy just because of inefficient processes, improper documentation or an inability to change with the times.

Appeal for denied claims:

Appeals work at two levels, with the Insurance payer as well as when being Audited by RACs, MICs or ZPICs.  When the documentation is good, denials can be re-filed and appealed with more authority which results in faster and higher payments.  Once a track record for excellent documentation is established, the Payers accede to review requests faster.

Reporting & decision making:

Clinical documentation supports medical research by providing all essential information and has been very helpful for healthcare agencies like the CDC and DHHS in disease management and faster decision making.  The case of the H1N1 virus is a good example of how proper documentation helped the agencies in responding promptly with advise and treatment protocols.

The need for documentation in medical billing doesn’t end with this short list. Every process in medical billing and coding needs proper and complete documentation that can help in the filing of clean claims and improve reimbursements.

If you are a medical practice that has chosen to outsource medical billing and coding functions, it is essential that you need to follow certain guidelines that will make outsourcing a success for you.

• Choosing the right medical billing company to outsource: The success of your outsourcing venture depends upon on the service provider that you have chosen. So, be specific with your requirements while choosing the company to outsource. Choose a medical billing company that has in-depth knowledge, good experience in the field and proven track of performance.
• Deciding the deliverables: After you have chosen a good medical billing company for outsourcing, the next important step is to decide the deliverables that you require/expect from your service provider, discuss the vital factors that determine the performance like turn-around-time, accuracy percentage and level of support that the medical billing company can provide you. Keep it clear in the agreement.
• Monitoring performance: Make sure that the medical billing company provides consistent performance. Analyze the monthly performance reports to review performance and find the areas of improvement. Maintain proper records for performance and ensure that the performance related issues are addressed immediately.
• Organized communications: Establish streamlined communications with your service provider. It is good to have a dedicated representative for your practice who can handle issues related to medical billing outsourcing, co-ordinate with the service provider and be a bridge between your practice and the service provider. A weekly update on the status can be useful in order to have a check if everything is on right track.
• Mutual assistance: Co-operate with your billing company whenever they need your assistance. With your help, the billing company will be able to perform better and with more ease.  Share the industry updates with them for enhanced operations. Meet the representatives of your service provider once a year or two for a detailed meeting on performance/ issues or challenges to be faced.

Following these suggestions would make your outsourcing venture more successful and help you reap maximum reimbursements from outsourcing medical billing

From a recent ICD-10 Update

Upgrading to Version 5010 involves significant planning and preparation. The Version 5010/4010A electronic standards upgrade deadline was January 1, 2012. However, CMS enacted an enforcement discretion period through June 30, 2012 for all HIPAA-covered entities. It you haven’t upgraded to Version 5010, it is important to begin testing now.

Denise Buenning, MsM, Acting Deputy Director, Office of E-health Standards & Services (OESS) recently took time to answer some of the industry’s top questions on the Version 5010 upgrade.

1. Is the industry up to date with the Version 5010      upgrade and taking steps to prepare for the ICD-10 transition?

Yes, we are hearing that the industry is progressing with Version 5010 implementation. We also continue to see from the Medicare Fee-For-service (FFS) group consistent increases across the board for 5010 transaction volumes and number of 5010 submitters.

We are also hearing that the industry is continuing to take steps to prepare for ICD-10. ICD-10 is a major undertaking for providers, payers, and vendors. It will drive business and systems changes throughout the health care industry, from large national health plans to smaller provider offices, laboratories, hospitals, and more. The updates will go much more smoothly for organizations that plan ahead and prepare now. A successful upgrade to Version 5010 now and transition to ICD-10 later will be vital to transforming our nation’s health care system.

2. What steps should I take if I am behind in the upgrade      to Version 5010?

There are a number of things that HIPAA-covered entities should do now. Communication among plans, providers, clearinghouses, and vendors, as well as other trading partners, is critical. Below outlines three steps providers can take now:

• Reach out to clearinghouses for assistance and/or take       advantage of any free or low cost software that may be available from       payers.
• Check with payers now to see what plans they will have       in place to handle incoming claims, and what interim alternatives are       available.
• Consider contacting financial institutions to       establish lines of credit to get through any possible temporary       interruptions in claims reimbursement as a result of not being Version       5010 compliant.

CMS has developed a fact sheet for health care providers, which discusses the risk mitigation steps in more detail.

3. How is CMS helping the industry prepare?

The Workgroup for Electronic Data Interchange (WEDI) and CMS are holding a webinar on ASCX12 5010 implementation and problem solving on May 23, 2012 from 1:00-2:30 pm ET. Registration is free. These online presentations are designed to gather feedback, track challenges and provide guidance to correcting ASC X12 5010 implementation-related issues.

WEDI and CMS previously held a webinar on ASCX12 5010 implementation, and  a replay of the webinar with the slides presented is located online.
Additionally, the CMS website has official resources to help the industry prepare for Version 5010 and ICD-10. CMS will continue to add new tools and information to the site throughout the course of the transition.

Guest Blogger: Angela Carmichael, MBA, RHIA, CCS, CCS-P, AHIMA Approved ICD-10-CM/PCS Trainer, HIM Product Development Specialist, J.A. Thomas & Associates

I just returned from an interesting Computer-Assisted Coding (CAC) Summit, with about 265 attendees.  ICD-10 , not surprisingly, seems to be the impetus to look very hard at CAC as many expect to experience a productivity decrease.

I see many benefits to CAC, especially when it can be used concurrently in the inpatient setting – although many are not using it this way, as of now.    However, when it is used concurrently with clinical documentation, it can be of immense help when a clinical documentation specialist and coder, for example, come up with different codes, pointing out the detail in the record that supports the coding.  This can save time and money for all involved.

My only concern is that some may put the cart before the horse – move too quickly to CAC without making sure clinical documentation processes are in place and functioning well.

Without a strong clinical documentation program, the inpatient side won’t benefit from CAC and the data won’t be any better.

My suggestion:  Make sure your clinical documentation improvement is on track and in order.  Then, phase in CAC for outpatient first, then do retrospective inpatient and then move to  full concurrent inpatient.  This makes sure the investment is solid and your automated coding is referencing correct and accurate data.

In changing the compliance date, CMS acknowledged the significant financial impact on those entities that had prepared for 2013. CMS estimates that additional expenses of as much as 30 percent of original ICD-10 budgets could be necessary due to a variety of factors. While many justifications for the delay have been cited, there is open acknowledgement that “in fact, giving small providers more time to prepare is the main justification for the one-year delay.”

CMS has addressed – and, seemingly, dismissed – many concerns regarding delayed implementation. For example, those individuals currently in training as ICD-10 coders now will need additional training, at an estimated additional cost of $6,000 per person. More broadly, this is tied to an accepted truism that “if you don’t use it, you lose it.” Consider the education that hospitals and other entities already have provided to their physicians, coders and other staff. Hospital contracts with ICD-10 vendors also will need to be extended, contributing to the 30 percent cost hike.

The proposal to delay ICD-10 implementation is fundamentally costly, and the cost falls squarely on those entities that currently are most compliant with the previously published rule. In other words, the best prepared will suffer the greatest economic damage.

Read more about my proposal for spreading out the burden more equitably.

Could you please help me find the career paths in health informatics? currently pursuing BSc in Public health Informatics. what do I study to become a good lecturer in Health Informatics?

What is in your opinion the best Health Informatics course (taking in account also future job opportunities) between the ones offered by Karolinska Institutet, Stockholm and City University, London?

Thanks,

Andrea

Hi all,

I'm a fan of paperless hospitals, I believe there may be only a few hospitals in the world that has gone completely paperless.

I like the fact that healthcare IT systems are helping hospitals to improve performance and digitize patient records. However, I've seen product demo's of some major health IT industry players in the UK..and I've noticed that all of the systems provide the option to print documents/forms of patient records although they are…

Reading the ISO 13485 standard doesn't helped me knowing how to manage the lifecycle of software medical devices. The QMS of a software company has to be adapted to be in conformity with ISO 13485.

ISO 13485 is generic

Since it is made for any medical device manufacturer or repackager or even distributor, ISO 13485 is very generic. Its requirements have high-level considerations without dealing with the specific tasks of any type of medical devices (excepted a few requirements for active implantable medical devices).
Software is a peculiar industry, compared to others, with a big design phase, a tiny production phase and huge maintenance (bugs fixes and enhancements) phase. Applying ISO 13485 for software industry needs a few adjustments.

What is mandatory?

ISO 13845 states that everything it contains is mandatory, excepted chapter 7. The content of chapter 7 is optional and a company has the right to exclude some paragraphs of this chapter, with good justification based on rationale about its organization and the type of medical devices it sells.
Dealing with software is like dealing with any other type of medical device. ISO 13485 doesn't make any difference for software and all requirements from chapter 4 to 6 and chapter 8 of the standard are mandatory. So, that's simple, you have to do everything that is mandatory in ISO 13485, excepted requirements in chapter 7, with good justifications!
OK, everything is mandatory in Chapter 4 to 6 and Chapter 8. Most of what they contain is implemented the same way for any company (certainly with differences in implementation, but not in the spirit of the standard). I want however to focus on a few points which it is not straightforward to deal with.

Purchase control

The types of purchase for a pure software company are very limited: computers, peripherals, storage media, books... This is not a big problem if you buy corrupted CDROMs or crap printer cartridges, you just replace them. This is just annoying and doesn't a-priori result in any danger for a patient. But purchase control is mandatory in ISO 13485, to ensure that purchased items have the good level of quality and won't be the cause of a hazardous situation. So a software company has to control its purchases and its suppliers even if the purchased items don't have any impact on the final product.
Yet, purchase control is still helpful, especially for the paper documents shipped with the software. But purchases remain a very minor source of risks, compared to a company which buys, say, sterile items.

Working environment

The working environment of a pure software company is very simple to set-up and maintain: offices for software developers and a coffee machine to share ideas. ISO 13485 has requirements about controlling the working environment. This is adapted to companies with sterile conditions, with production lines... But this is abolutely not a big deal for software companies. Controlling the working environment is still mandatory and a software company could limit this control to the good working conditions of the software developers: good PC with good tools, good servers, processes to archive data ... It is true that a developer working on a bad/slow workstation could have an impact on the quality of the software but this is again a very minor source of risks, compared to a company which manufactures goods.

Production

ISO 13485 has a list of requirements about production. This is obviously mandatory for any company, since the quality level of products as to be controlled. This is also the case for software and production shouldn't be underestimated. A software company shall have a rigorous production process/procedures to ensure that the delivered software is the right one: software version + patches, plugins, extensions (customer tailor made or not), configuration files, input data ... All what is shipped with the software itself shall be controlled and this can result in a list of procedures, work instructions and forms. Again, production shouldn't be underestimated.

CAPA, Change control, Post Market surveillance, customer communication

Maintenance of software is an important task. A software is never finished and there are always fixes and enhancements to do. CAPA, Change control, Post Market surveillance, Customer Communication are activities required by ISO 13485, which are all "active" when the software is used and maintained. All these processes required by ISO may (and will, for sure!) result in bugs discovered in the software.
The last chapter of IEC 62304 is devoted to problems resolution (ie how to fix problems and especially software bugs). This problem resolution process/procedure of IEC 62304 should be linked to the other activities of ISO 13485 I quoted above.
When something goes wrong with the software, should it be discovered by a sales person (customer communication), by the regulatory affairs (post market surveillance), by the quality manager (CAPA), it should be "passed" to the software teams, which will treat it according to IEC 62304.

What to exclude?

Having quickly seen other chapters, back to chapter 7. You will find that it contains a few activities about cleaning, sterilizing and specific tasks for active implantable devices. There are good chances that your company excudes the following requirements if it sells pure software (no hardware):

• Cleanliness of product and contamination control: §7.5.1.2.1,
• Particular requirements for sterile medical devices: §7.5.1.3 and §7.5.2.2,
• Particular requirements for active implantable medical devices and implantable medical devices: §7.5.3.2.2 and §8.2.4.2 (not in §7 but still excluded).

Still in chapter 7, there is another possibility of excluding requirements, your company doesn't use monitoring and measuring devices (MMD) in design, production and maintenance.
A software doesn't produce physical measurements and usually the software development team doesn't use MMD to design software. There are good chances that your company excludes the following requirement:

• 7.6 Control of Monitoring and Measuring Devices

Warning; if you use measurement devices during tests phases, then you have to implement §7.6. Eg: your company sells software for post treament of ECG data. If you use libraries of archived data to do your tests, you can exclude §7.6. I you use a real ECG to do your tests, it is a MMD and you can't exclude §7.6.

Design is mandatory for software

Last word about chapter 7, but not least, design activies are in section §7.3. So they are optional!!! It is possible for multiple reasons for a lot the types of medical devices to exclude design, that's why it is there. But this is absolutely not a good solution for software medical devices. So, §7.3 of the standard about design is de-facto mandatory for software medical devices manufacturers. This is consistent with IEC 62304.
Without design procedures, it's not possible to implement the requirements of IEC 62304. So design is mandatory for software medical devices.

QMS of a pure software company

To end with a summary, here are the main characteristics of a QMS for a software company:

• "Support" activities like purchase and working environment are very limited
• Design is mandatory, consistent with IEC 62304
• Production shouldn't be neglected
• Activities when software is used and maintained like NC, CAPA, vigilence, post market, regulatory affairs, customer communication should have a link to problem resolution of IEC 62304
• Anything about sterile products and implantable products is excluded

To conclude, IEC 62304 helps defining the way things are implemented with respect to the generic requirements of ISO 13485.

Note: I did not mentioned risk management in this article, this is deliberate and should be described in another article.

Hello,

Back on my blog after a few days off. I wrote in my post about classes of software that I would release a template on user guide. Here it is!

After the Usability Specification template, here is the User Guide template.

It contains some sections that you should not have tough about at the first time, like safety precautions and contact information.
It contains also parts that are applicable only to companies which sell hardware and software. Selling hardware brings more risks and constraints, which have impacts on the user guide. The lucky companies which sell software only are not subject to such constraints!

It tried to gather every activities linked to the use of software: installing, using, maintaining and uninstalling. However, it may be split into several documents: user guide, installation manual and maintenance manual. If the user is not the person who installs and maintains the software, you'd better have a separate document for user functions and another one for installation and maintenance functions.

By the way, my next post will be about application of ISO 13485 to software manufacturers.

Stay tuned, my list of templates is growing fast!

I gather all my templates on the templates page. You'll find them all there.

Please, feel free to give me feedback on my e-mail contact@cm-dm.com

I share this template with the conditions of CC-BY-NC-ND license.

I didn't have time to post anything worth it this week.
To give a side view of my last post about software classes, here is a link to DO-178B on wikipedia. It is the reference about software embarked in aircrafts.
If you take time to read this document, you will see that it goes very further than what we have today in IEC 62304. The constraints about design on high classes are very very hard to respect. That's normal, when you think that software is used in flight commands and other stuff in the cockpit.
It has some side effects, mainly to stretch software development projects, and to ban software from some parts of the plane, for cost-driven reasons.
For example, a microcontroler plus software plus electric motors would be perfect to memorize and retreive the position settings of the pilot's seat. But the cost to develop such software is very high, as the pilot's seat is seen as a critical component. Aircraft manufacturers prefer replacing software and microcontroler by good old analogic electronics to do the same task on some models.
In my humble opinion, the constraints of the two highest classes for software in aircrafts would be to high for medical devices. There is always a pratician, or an emergency medical service, able to "catch" the patient if something goes wrong. Whereas there is nobody to "catch" a falling plane if its flight commands fail. The consequences of risks are far higher in aircrafts, with potentially hundreds of victims in an accident.
That is why classes A, B and C, and their design constraints are enough for medical devices.

Next week, I'll talk about exemptions of ISO13485 for standalone software medical devices.
Bye.

NIST would like suggestions from the public regarding how federal agencies should be involved in the standardization system. Standardization areas include but are not limited to: smart grid, health information technology, cybersecurity, emergency communications interoperability, radioactivity detector and radiation monitors. Public comments are due by February 7, 2011.

Read the full story:
http://www.healthcareitnews.com/news/nist-seeks-input-government-involvement-standardization

By yesterday, two states had already sent out checks to Medicaid participants just two days after registration for the program had opened. The checks came from Kentucky and Oklahoma, with many other states soon to follow. There has been some skepticism regarding how smoothly the meaningful use incentives programs will go. Maybe these recent events will put people more at ease.

Read the full story:
http://www.healthdatamanagement.com/news/meaningful-use-ehr-incentive-check-medicaid-41699-1.html?ET=healthdatamanagement:e1596:159225a:&st=email&utm_source=editorial&utm_medium=email&utm_campaign=HDM_Daily_010611

Experts are already making disheartening predictions for health information privacy in 2011, such as increased fines, data breaches, regulations, penalties, etc.

What are your thoughts on the issue?

Read the full story:
http://www.healthcareitnews.com/news/experts-name-top-7-trends-health-information-privacy-2011

Update: Be patient with the Samahope.org site as they roll out over the next few days… 

Welcome to PT Think Tank’s new website design and Happy Mother’s Day to all the mom’s out there!

Today, we’re going to jump right in and get real on Mother’s Day. So real, in fact, that we’re going to talk about fistulas. Obstetric fistulas, to be specific. The kind that form mostly in impoverished countries after childbirth, we’re birth trauma causes tissue death and connects parts of the mother’s pelvic anatomy that should never, ever be connected.  Women suffering with obstetric fistulae are ostracized by husbands and communities and suffer from infections, poor quality of life, and even death.

According to The Fistula Foundation, the occurence of new obstetric fistulae number about 50,000-100,000 annually, while the global capacity to treat this condition is only around 20,000. While this condition is extremely rare in developed countries, the World Health Organization estimates that between 2 to 3 million mothers in poor countries struggle with it. While the cause of obstetric fistulae are complex,  with as little as $450-$1000, the condition can be effectively repaired surgically.

My very compassionate and talented fried, Michelle Greer let me know about Samahope. Samahope.org is attempting to tackle this problem. This new venture is working to crowd-fund this procedure for women who can’t afford it. In an elegant interplay between philanthropy and technology, Samahope.org allows donors to select the individuals you want to help, donate simply using PayPal, and even track the outcomes for the surgeries they helped fund. Samahope.org is a project of Samasource.org, a non-profit based out of Silicon Valley who is working to reduce poverty through creating jobs via the innovate idea of mircrowork, connecting people with jobs over the internet. Leila Janah, the founder of Samasource, spoke recently at a TED event in Brussels:

Get involved and for this Mother’s Day, in addition to that nice pot of flowers and brunch we all like to confer upon our maternals, give the gift of life. Samahope.org is beginning their rollout today. In fact, they have but one tweet. It says, “How can you help change a life with only $20? Easy… I just did.“

Donate Now

Recently, the physical therapist social media world has been a buzz with #SolvePT. I added my thoughts on this in a separate post. This movement made me reflect on a Ted Video I watched and enjoyed recently. It got me thinking and it spawned this week’s thought.

Inspired by the video below by Brene Brown, we need vulnerability to connect. I believe the recent #SolvePT is a nice illustration of connection, albeit virtual, happening within the physical therapy profession. Now, taking the leap to join social media, and then leaping into the conversation means putting yourself out there in a virtual, but very real sense. It means expressing thoughts, views, and ideas. Ideas the world and other PT’s can read (and critique!). It is social media vulnerability, but we need it to truly connect.

Connect!

Now, what about in real life; what about the patients we serve? Many, if not all, come to us in vulnerable circumstances. Sharing their stories, their illness narratives, they are vulnerable. Are we, individually and collectively, creating an environment that welcomes and nurtures vulnerability in order to facilitate connection, understanding, and transformation?

You need vulnerability to connect. What can we do better in our personal and professional lives? Individually and collectively? What can we do better in education of our students and patients?

Thoughts? @Dr_Ridge_DPT

Recently, a new hash tag has emerged in the physical therapy twittersphere: #SolvePT. Selena, via the Evidence in Motion Blog, shared her thoughts in a post The Pulse of Physical Therapy. Dr. E of the Manual Therapist also briefly highlighted this new hash tag in a post.

#SolvePT

Initially, discussions focused on financial issues of physician owned physical therapy services (POPTS), student loans, payment, and educational costs. But, today involvement and content was rich with various contributors and topics. Physical Therapist Twitter regulars such as myself (@Dr_Ridge_DPT), Larry Benz (@PhysicalTherapy) and @SnippetPhysTher were present. @PTThinkTank even tweeted a few insights. Other tweeps included:

• Physical therapists from various states and practice settings
• Professional Organizations: @AAOMPT  @APTACO
• Sections of APTA: @SPTSAPTA (Sports)  @AcuteCarePT
• Physical Therapy Students: @APTASA (Student Assembly) @MattDeBole
• Physical Therapy Programs: @PacificDPTweet

Web 2.0 principles allow us to crowd source and brainstorm with a much wider audience; geographically, practice setting, and expertise. This hashtag will allow for the recording and analysis of a wide range of view points and ideas. We can follow the evolution of topics over time. This stream and  medium could be leveraged by larger, more formal organizations (are you listening APTA?) for idea generation  to guide future task forces and initiatives. In fact, some of the issues, solutions, and thoughts for future direction are solid. #SolvePT is already evolving into a task force.

My Insights and Thoughts

There was a lot of focus on “best practices” in physical therapy. Defining, measuring, communicating, and then teaching best practices is extremely challenging. Todd Davenport of @PacificDPTweet, made the observation that “best practice” is a moving target given the evolution of research, science, and understanding. I agree. Further, who defines best practice? I think we must look beyond a specific patient and episode of care when defining, analyzing, and teaching best practice. In addition, we must look at multi-level outcomes. For example, for an outpatient perspective we can not just look at the patient specific outcome of that episode of care, the time/number of visits, and it’s cost. That is a too narrowly focused frame of reference. We should broaden our lens, and our potential for impact. We need to also need to consider (and target?) recurrence, future health care costs, risk reduction for other medical conditions, and overall health/fitness. Cardiopulmonary fitness is maybe the most dramatic modifiable factor to prevent disease, morbidity, and mortality.

I brought up the topic of physical therapists in hospital intensive care units. Johns Hopkins performed a quality improvement project where they staffed 1 physical therapist for a 16 bed medical ICU. Their estimation is that by decreasing ICU length of stay and increasing patient mobility/function the hospital, and thus the health care system, saved an estimated 5 million dollars over a 1 year period. The internal investigation lead to the hospital staffing 2.2 full time physical therapists solely in a 16 bed medical ICU. This is a dramatic change in practice focused not on productivity or reimbursement, but on VALUE, risk reduction, and other broader outcomes.

Unfortunately, in discussing best practice no attention was brought to the actual content of current PT programs. In my opinion, pain science/physiology, basic neuroscience, critical thinking, philosophy of science, cognitive biases, and metacognition are vastly lacking from our curriculums.

The teaching and study of pain should be integral in all PT education, both didactic and clinical. We have neuromuscular, musculoskeletal, cardiopulmonary, and or medicine tracks in our programs. Why do we not have a specific pain track? Or, at least a focus and integration of neuroscience and pain physiology into our other courses? Regardless of practice setting, the majority of our patients will have a primary or secondary complaint of pain. Joe Brence, who blogs at ForwardThinkingPT, started an online petition regarding this exact topic. I recommend you sign it HERE.

In order to be “evidence based” (or more accurately Science Based) we need extensive training in the philosophy of science and critical thinking including prior plausibility, research design, and article analyses. To assume that students entering PT programs received such instruction as undergraduates is, to put it nicely, a huge assumption. How are we to make appropriate clinical decisions if we do not understand our inherent cognitive traps and biases? How are we to correct them, if we can not even recognize them? The skill of appropriately analyzing a single article based on design, statistics, and results in the context of plausibility, basic science, and the state of other literature AND THEN applying that to everyday clinical practice is what being a master clinician-scientist is all about. And, that is what we need to strive for. The title of Tamara Little and Todd Davenport’s recent editorial in the Journal of Manual & Manipulative Therapy sums it up quite nicely: Should we be expert clinicians or scholars? The answer is yes.

How do we generate results from this passion and discussion?

1. How do you think we should #solvePT?
2. What are the most pressing issues in education, payment, practice, and our evolution?
3. How can we focus some of the general issues and proposed ideas into specific and concrete action; solutions!?

#SolvePT has been thought provoking. Hopefully, it will continue to grow. I foresee big potential in this type of interaction.

This morning we announced the release of our latest report: 2012 HIE Market Report: Analysis and Trends of the Health information Exchange Market. As we found in last year’s report, the HIE Market and the vendors that serve it continues to be a very dynamic.

In little over a year we have seen several vendors exit the market, several others enter and the acquisitions of Carefx by Harris and MobileMD by Siemens. We also saw Microsoft pull completely out of the clinical market by turning over all its HIT assets (except HealthVault) to the new joint venture with GE, Caradigm.

Yet in spite of all this turmoil, the market continues to see spectacular growth in excess of 40% in 2011. The big news with all this growth is that only a small portion of it is coming via the HITECH Act and the various statewide HIE contracts that were awarded. No, the big market that literally all HIE vendors are now targeting is the private, “enterprise” market. Healthcare organizations (HCO) of all sizes are now looking to deploy HIE technology to not only meet Meaningful Use requirements, but respond to the pending changes in reimbursement, moving from a fee for service model to one that is based on outcomes.

To be successful under these new payment models, HCOs must better manage operations and the complete care cycle of a patient across care settings. In a community of heterogeneous EHRs, HCOs are adopting HIE technology at an accelerated rate to unlock the data silos of EHRs across the community to enable higher quality of care.

Arguably, the 2012 HIE Market Report’s most significant finding is…

The healthcare sector is rapidly moving to the post-EHR era. The value of patient data is not in the data silos of EHRs but in the network that an HIE supports.

The report provides the most comprehensive overview of the market and what are the significant trends that are driving this market forward. The report also provides a deep dive review of 22 leading HIE vendors, including product capability assessment and market presence. This information, compiled through in-depth research and countless interviews, provides all HIE stakeholders with the most accurate view of the market today.

It is our sincere hope that the information contained in this report will contribute to furthering the success of HIE deployments in the future as we strongly believe that only through health information exchange (the verb) can we improve the quality of health delivered within a community and ultimately, the nation.

Been pretty quiet here on the Chilmark Research site for the simple reason – we are doing one heck of a lot of research which you’ll be seeing the results of in the not so distant future.

Primary among those research efforts is the update to the 2010 HIE Market Report. The last report was extremely successful and highly regarded among those in the know. For example, a CEO from one of the top HIE vendors told us:

By far, Chilmark Research has done the best research on the increasingly critical HIE market – no one else has come close to providing the in-depth research that is contained in the 2010 HIE Market Report.

And it is not just the HIE vendors who appreciated the report as we sold quite a few to healthcare organizations who have been using the report to assist them in their strategic decisions and ultimately vendor selection process.

But the HIE market is evolving quite quickly and thus the need to provide a refresh of the report. For example, of the 21 vendors profiled in the last report, 7 will not show up in the next edition. Even with that change, there are more entrants into what has become a lucrative market (albeit still relatively small) and in the 2012 report we will have in-depth profiles of 22 HIE vendors.

To give you some brief insight into the report, following is the intro to Chapter 3.

“The more things change, the more they stay the same.”

This French proverb accurately characterizes the state of the HIE market and the vendors who serve it. In last year’s report we commented on how the market was becoming increasingly crowded and competitive. We profiled 21 vendors in that report and a third of them did not make it into this report. Some exited the market (ICW, MedPlus, MEDSEEK, Misys, PatientKeeper, Telus), others acquired (Carefx and MobileMD) and then there is the folding of the HIE assets of GE and Microsoft into the new entity Caradigm. This year we have 22 vendors profiled including: Caradigm and Microsoft (still difficult to know what will become of their joint assets, but we provide some guidance), Harris, who had acquired Carefx, Siemens, who picked up MobileMD and some new entrants including 4medica, Certify Data Systems, the young start-up GSI Health and HealthUnity. We even broke from tradition, if you can call one year a tradition, and profiled one of the leading EHR vendors, Cerner, who contrary to prevailing EHR vendor wisdom, or at least strategy, is creating an open HIE platform.

The market is as competitive as ever with a monumental shift towards the enterprise market. Some vendors have been serving this market all along, others, whose focus has been the public market are to varying degrees of success making the transition to the enterprise market. But despite this overwhelming shift to the enterprise market, the HIE market remains no less mature than it was last year. The solutions on offer vary significantly and in our interviews with vendors, consultants and end users we found a market that really has not defined a clear set of requirements for the HIE. There is always the ubiquitous desire to facilitate orders, referrals and distribution of results but beyond that, the needs of a given HCO can vary greatly, which has subsequently led to continued market confusion as to what an HIE is and is not.

With this report, Chilmark Research once again has applied its deep research methodology (see Appendix B) to provide a clearer picture of where this market and the vendors who serve it are today and where it is heading. The profiles contained in this report are not meant to provide an exhaustive analysis of each vendor’s solution and business strategy. Rather, their purpose is to provide a concise overview of leading HIE solutions in the market today, their strengths and weaknesses, what sector(s) of the market that the vendor has had particular success in and provide insight as to an HIE vendor’s future direction. Armed with this information, the reader will gain a clear picture of currently available solutions enabling one to create a short-list of those worthy of more in-depth internal review and follow-up for their own HIE initiatives.

In our opinion, we are slowly but surely beginning to enter the post-EHR era. The U.S., federal government’s push for physician and hospital adoption of EHRs, via the HITECH Act, appears to be having the intended affect. The recent Robert Wood Johnson Foundation study published in the April 2012 edition of Health Affairs has physician adoption and use of EHRs now at 57 percent. But the value of those electronic patient records is not in the data silo of a given EHR, but in how patient data can be aggregated and used to facilitate care coordination across care settings and subsequently improve the quality of care a patient receives. This is the province of the HIE and where the real value of electronically recording a patient’s health will reside, not in the silo of the EHR, but in the network of the HIE.

Please bear with us and our lack of frequent posts. We are working hard here at Chilmark Research, which can make it a challenge to find that extra bit of time to write for the public. Once the HIE Report is released (next week), we should be getting back to a more regular schedule of posts to this website. Stay Tuned.

A couple of weeks back, Neil Versal wrote an interesting article for mobihealthnews on mHealth App development and adoption trends. While agreeing with some of the thesis of his argument, that many Apps have little relevance to the broader populace and seem to be more focused on the Quantified Self geeks, there are a couple of points he made that give a false impression of what our research and personal experience have found in this emerging market.

First, there was the argument that those who may be in the greatest need of using an mHealth App to manage a chronic condition may not have the wherewithal to identify and use an App. This is true for pretty much the entire population and not only those with a chronic disease. Our research for the upcoming report, mHealth for Provider-Patient Engagement, found a market where most mHealth App developers struggle to get users, particularly those with chronic illnesses, to continuously use an App.

Where an mHealth App has seen success is when it becomes a critical component of a care management process and a patient receives periodic feedback from a clinician. Such was the case in an urban, predominantly poor neighborhood in Washington D.C. wherein diabetic patients actively engaged in the use of an App to record their glucose readings for they were getting feedback from clinicians. Therefore, our thesis is that the issue is not whether the App has been designed for a given populace but its potential use (success) rests more with how and more importantly who deploys the App. The vast majority of the populace needs that clinician guidance and support in use of an App to manage a chronic condition – it will not work in a vacuum, it must become a part of the care management process.

However, in our conversations with a number of physicians we found a common theme that most are struggling to figure out how enabling their chronic disease patients with such tools and follow-on monitoring will fit into their existing workflow. We see this as code for: “How will I be reimbursed for this effort?”

Good question. The impending changes in reimbursement and subsequent move towards capitation may provide the path forward without the requisite CPT codes. There remains the challenge of how EHRs may accept such patient entered data from an mHealth App as today we do not know of any that can support this capability but that is a topic for another post. The important point we wish to make is that mHealth can play a role an important role in the care process, it just needs a advocate to drive its use, that advocate being a clinician/care management leader to help guide and support he patient.

The other issue we wish to raise is the oft-cited numbers that are thrown about of how people download various mHealth Apps and then rarely, if ever use them.

All of us who have a smartphone likely have a few Apps that we have maybe used once or twice and have forgotten about or tossed them for they did not appeal to us. But that does not necessarily mean lack of use equates to lack of value. Some Apps are not meant to be used frequently, iTriage is one of them, but I sure am glad I have it on my phone.

Now I have been a fan of iTriage from its early founding and was happy to hear that they found a willing suitor in Aetna when they were acquired last year. Their solution, while a little intimidating at times, is one of the better mHealth Apps out there in doing self-diagnosis, which is what I had the opportunity to do last month when visitng my parents.

Late one evening (actually about 3am) I awoke not feeling quite right. Next day I learned that I was not the only one as both my sister-in-law and father where also feeling under the weather. After a couple of days, my sister-in-law and I began to feel better. Such was not the case for my father. After some exploratory questions, came to the conclusion that we all suffered from some form of food poisoning. As my father’s health declined I asked him more specific questions about his symptoms. He was suffering from loose stools, weakness, fever and painful urination (sure sign of UTI). Using the iTriage App I triaged my father eventually settling on the likely culprit: E. Coli poisoning.

Knowing this was a very nasty disease (yes, it kills), you don’t waste time getting treatment. Took father to the local ER where they immediately put him on an intravenous feed of some pretty strong antibiotics and to hydrate him. The attending physician took a culture and stated they would have an answer  in some 36 hrs as to what was at the root of his symptoms. Sure enough, when the physician got back to us he confirmed that it was indeed E. Coli poisoning.

Prior to this event, when was the last time I opened up the iTriage App? Really can’t recall but it was likely to demo it to someone and probably more than six months prior. But this is not an App designed to be opened and used frequently, it is designed to be used when you need it. And that is part of the problem with a lot of these broad pronouncements about the use, or lack thereof, of mHealth Apps: some of these Apps simply aren’t meant to be used frequently but you’re sure glad you have them when you need them. The mHealth App market is far more nuanced and most do not dig deep enough prior to making broad pronouncements instead painting the whole sector with one stroke of the brush which is a disservice to this emerging sector.

As to my father, he has made a full recovery and one of the first things he asked me when he got home from the hospital was: What was that App you used? Can I put it on our iPad? Done. Now if only iTriage would make an iPad version of their App then my father, and maybe others would be even more delighted.

Web 2.0 was coined as a cool name for a conference about the state of the internet back in 2004. Kind of a play on the fact that software is released in ‘versions’ (1.1, 1.4, 1.2.3.1.2, etc, etc) whereas the web is clearly evolving and branching in a way that defies this kind of classification.

Web 2.0 draws an arbitrary line that says the current state of the web is significantly different now from how it was a few years ago.

There’s been a lot of talk about what Web 2.0 really means and what it doesn’t (here’s the official line from Tim O’Reilly who coined the term).

Here’s an anthropological take on Web 2.0:

Learn about heart anatomy and physiology through the power of song…

More medical videos.

This online app could be use for students creating their own learning projects or for staff to create course notes and resources for their students.

I. PURPOSE
To establish procedures and guidelines governing the testimony for witnesses
from the public.

II. CANCELLATION
This policy cancels and supersedes all prior memoranda regarding testimony for
witnesses from the public.
 
III. POLICY
In order to ensure an orderly public hearing, all witnesses from the public
shall register in person during the first day of the hearing. If a witness fails to
register during the first day of the hearing, the witness will not be allowed to
testify during the hearing. If multiple witnesses are present on behalf of one
party, the group can elect up to three representatives. The representative's
comments will be limited to five minutes each up to a maximum of 15 minutes.
Individual comments will be limited to five minutes each. Further, a witness in the
hearing that has provided testimony shall not testify as a witness from the public
in the same hearing.

INFORMAL DISPUTE RESOLUTION:
In accordance with 42 CFR 488.331, you have an opportunity to question cited deficiencies through an informal dispute resolution process. To request an informal dispute resolution, please submit in writing the specific deficiencies being disputed and an explanation of why you are disputing those deficiencies to:

                                    Informal Dispute Resolution Review Committee
                                    Office of Health Facility Licensure and Certification
                                    408 Leon Sullivan Way
                                    Charleston, WV 25301-1713

You may also send your request via email to DHHR.OHFLAC.@wv.gov. 
This request must be sent during the same ten (10) calendar days you have for submitting a Plan of Correction (POC) for the cited deficiencies and must be contained on a document separate from the CMS-2567L, which contains the POC. 
You may choose between an informal dispute resolution (IDR) and an independent informal dispute resolution (IIDR).  You must clearly indicate your choice in the attention line of your request and the subject line of your email. An IDR will be completed by OHFLAC staff not associated with the referenced survey event.

Per West Virginia State Code §16-5C-12a, an IIDR will be completed by an independent review organization.  If an independent informal dispute resolution process is selected, the matter will be assigned to one of three independent review organizations accredited by the Utilization Review Accreditation Commission.  The facility may be subject to certain costs such as:
•     The cost of a face-to-face conference if one is requested; and
•     The cost charged by the independent review organization, should the facility not be successful in its dispute.

Please call us at 304-346-4575 if you have any questions.

Just today we announced the expansion of HealthVault in China, specifically in the Jiangsu province of Wuxi. This is definitely a big step in the international expansion of HealthVault outside of the United States and joins the other international deployments in Canada (doc), Germany and the UK.

Microsoft Corp. and iSoftStone Information Technology (Group) Co. Ltd. have signed an agreement that enables iSoftStone to introduce Microsoft HealthVault technology to the Chinese market. HealthVault, a personal health application platform, enables individuals to store and manage their health information in a personal, online account. Initially focused on Wuxi, in the province of Jiangsu, the vision of the Microsoft-iSoftStone relationship is to enable citizens to connect to various health systems and services run by government organizations, physicians, hospitals, pharmacies and even fitness facilities for a comprehensive view of their personal health information. iSoftStone will be the exclusive operator of HealthVault in Wuxi and will develop and offer the HealthVault-based services to developers, application providers and device manufacturers to provide citizens with tools that will help foster dynamic, trusted and personalized healthcare.

Check the rest of the press release online.

iSoftStone Signs Agreement With Microsoft to Develop Citizen Health Solutions in China Using HealthVault: Digital health innovation center is first step of a joint healthcare effort in Wuxi, China.

Well, this is at least a partial excuse for my absence from this blog :-)

Today we announce the acquisition of Sentillion, Inc demonstrating again Microsoft’s level of commitment to the healthcare industry.

Many of you reading this are familiar with Sentillion and this acquisition is the culmination of years of successful partnership between the two companies. Our primary goal with the acquisition is to make it easier for healthcare professionals to deliver better patient care by streamlining access to multiple IT applications and patient data by combining Amalga UIS and Sentillion’s solutions for single-sing-on and context management.

So far we have received excellent feedback and I am really excited about the Sentillion folks joining the ranks of the Health Solutions Group and Microsoft.

For more detail please have a look at the press release.

The HealthVault Solution Conference that we did last year has evolved into a broader event that includes more of the solutions that Microsoft has to offer in Health.

The Connected Health Conference will be held on June 10-12 in Bellevue, WA and we’re going to feature a lot of content both around Amalga UIS and HealthVault and an exceptional lineup of speakers including David Kibbe, Governor Michael Leavitt, Uwe Reinhardt, Mark Smith and Peter Neupert. Lastly we’re going to have a few surprises in store both for HealthVault and Amalga UIS, so make sure you rush and register, we have limited space available and we expect a lot of people!

The folks at HIMSS are claiming that the 2012 conference in Las Vegas a couple months ago set a world record for the most tweets at a health conference. (I’m checking to see who keeps such records.)

By the numbers, according to HIMSS:

• The #HIMSS12 hashtag was used 28,434 times.
• HIMSS12 averaged 167 tweets per hour.
• HIMSS12 was mentioned 33,247 times in social media, more than double HIMSS11 (which itself was more than double HIMSS10).
• The keynote by Twitter co-founder Biz Stone generated 7,595 tweets, beating out the 7,047 tweets from Dr. Farzad Mostashari’s keynote.

This infographic from HIMSS tells more of the story about the whole conference.

I am not surprised Brian Ahier and Regina Holliday had so much influence on social media at the conference. Ahier moderated the Meet the Bloggers panel I was on.

I was, however, surprised to the breakdown of mobile devices accessing the HIMSS conference’s mobile site. Apple with 70 percent sounds right, particularly when you consider how many iPads were in evidence, but I would have guessed Android would have more than 14 percent share because it’s so popular for smartphones and BlackBerry more than 2 percent because a lot of enterprises still use that platform. I guess I’m one of the few people left in health IT with a BlackBerry.

UPDATE, Friday, April 27: It was healthcare social media consulting firm Symplur that tracked the tweets and announced the record. There’s more data here, though my head starts spinning when someone discusses stuff like slopes of equations.

Related posts:

1. Let’s get Biz Stone to attend New Media Meetup at HIMSS12
2. Podcast: HIMSS CEO Steve Lieber previews HIMSS12
3. HIMSS12 notes

Remember James C. Tyree, the University of Chicago Medical Center board member who died last year from a preventable medical error at the very same hospital he was on the board of? His estate has reached a $10 million settlement with the prestigious teaching hospital for “alleged negligence,” the Chicago Tribune reported.

As I previously wrote, Tyree died from an intravascular air embolism, the result of an improperly removed catheter. That just happens to be one of the National Quality Forum’s so-called “never events.”

Tyree, as chairman and CEO of  financial services firm Mesirow Financial, was pretty well-off. He also should have gotten VIP treatment at U. of C. Medical Center since he was a board member. Yet his money and connections could not save him from a preventable error that really should never happen.

Think about that the next time someone tells you that having health insurance automatically gives you access to good care and that the wealthy get better care than the rest of us. Health insurance just means the insurer will help pay the bills — and often the bills rise (as does hospital revenue) — when there’s a preventable error, as seems to be happening with my own father this week. (He’s still in the hospital, though the pneumonia has subsided.) Being a VIP at a teaching hospital just means you might get faster service, more — not necessarily better — care and perhaps direct supervision from executive faculty, not just residents and the occasional attending physician.

Poor quality is epidemic in American healthcare. Don’t let anyone tell you otherwise.

Kudos to David Doherty of Ireland-based telehealth provider 3G Doctor for this summation of the problem, which he tweeted in response to the post about my dad:

In 2012 where else but the sickcare industry do you make more money by failing http://t.co/pUOebYho Hope Dad gets well soon @nversel

April 23, 2012 3:46 am via webReplyRetweetFavorite

@mHealthInsight

mHealth Insight

Keep spreading the word: It’s quality, stupid.

Related posts:

1. Clinical informatics certified as medical subspecialty
2. Podcast: Dr. Bill Bria on CMIOs and medical informatics
3. EMR and HIPAA: Medical establishment clings to status quo

My dad, who already was dealing with a serious health issue, was hospitalized a week ago with what turned out was a urinary-tract infection. That cleared with antibiotics in a couple of days, but then he developed a fever, so he could not be released. While we were waiting for that to subside, he developed a hospital-acquired infection, namely pneumonia. He’s still in the hospital and the hospital is still able to bill Medicare for all these extra days — plus the physical therapy he will get in a rehab center that the hospital owns once he’s discharged because being in bed for a week is a serious setback to his original condition.

If anyone thinks the U.S. has the “best healthcare in the world” and that good insurance will get you good care, think again. Please pass this link around and share your own stories in the comments section so we can help spread the truth about quality deficiencies and perverse financial incentives.

Related posts:

1. An EHR hits close to home
2. Hospital quality and journalism quality
3. It’s the quality, stupid.

I am not in favor of messing with the insurance system for this purpose but have argued for a more direct approach. Under what I call a “no-give, no-take” rule if you are not willing to sign your organ donor card you go to the bottom of the list should you one day need an organ. Israel recently introduced a version of no-give, no take which gives those who previously signed their organ donor cards points pushing them up the list should they need an organ transplant–as a result, tens of thousands of people rushed to sign their organ donor cards.

What’s got Charles Johnson (the wrong-headed Charles Johnson of Little Green Footballs, not the right-headed anarchist Rad Geek) so worked up?

Now the GOP Wants to Permit Any Employer to Deny Contraception Coverage

What’s all this “permit” and “deny” stuff?

An employer doesn’t (or at least shouldn’t) have to offer health insurance as a job benefit at all (he or she may choose to do so, including as part of some contract negotiation or whatever, of course).

And if an employer does offer health insurance as a job benefit, excluding this or that item from said offering isn’t “denying” anyone anything, nor should any “permission” to exclude anything, nor any excuse for excluding anything, be required. As long as he’s not lying about what it is he’s offering, I’m free to take it, leave it, or try to negotiate something different.

There’s no “right” to force someone else pay for or deliver whatever health care you might happen to want, and there never will be, no matter how many times Johnson clicks his heels and shouts “war on women’s rights! … [W]ar on contraception!”

The whole “religious exemption” thing is just a distraction. I suspect that’s where you’ll find most objections to covering contraception in particular, for the simple reason that most employers and insurers would rather pay for contraception, vasectomies, tubal ligations, etc. than pay for pre-natal care and delivery of a baby, then cover that baby’s health care expenses as well. But the general principle extends far beyond religious objections.

Maybe my employer finds out that he or she can save $10 per employee per month by offering us policies that exclude sports injuries. Unless we have a contract specifying otherwise, why should he be mandatorily out $10 extra a month so that I can play rugby or ride bulls on the weekend?

Or maybe I’ve had myself snipped and my significant other has had her tubes tied. Why should we not be able to buy a policy that doesn’t cover (at an extra premium cost) a bunch of services we’re never going to need?

Hey, maybe … no, not just maybe … the details of what health insurance we buy (or don’t buy), or negotiate (or not) with our employers, are none of Barack Obama’s and Kathleen Sebelius’s business.

Princeton economist, Uwe Reinhardt, contributes regularly to The New York Times Economix Blog. Recently he wrote, in
“Health Care Payers Push Back Against Costs“ that high U.S. healthcare costs are driven by several factors:

• American’s over-use of high-cost/high-tech services owing to some American’s being over-insured.
• High administrative costs (mostly in the health insurance area)
• Higher prices paid by Americans for healthcare services and products

On this latter point – higher prices – he points to an imbalance of power between the buyers (and payers) vs. the suppliers of healthcare.

[...]higher prices are the product of a deliberate strategy, hashed out in our political bazaars between the supply side of health care and state and federal legislators, always to keep the payment side of our health system fragmented and relatively weak vis à vis the supply side of health care.

He also notes how difficult it is for patients to do price comparisons – “price opacity” he calls it. He saves his strongest reaction to the system of price discrimination found in healthcare today. Providers charge (and are paid) differently depending on who pays the bill. Insurance companies demand substantial discounts from hospitals, and Medicare reimbursements are significantly lower than provider costs.

Reinhardt warns providers to prepare for an era of increasing price information and comparisons, along with other purchasing initiatives.

To add my own commentary: Our public discourse on complex problems often veers towards finding the villain – the “bad guy.” Once identified that villain gets all of our intention, and if the political stars are aligned government legislation and regulation results. If healthcare costs are an inflated balloon, then pushing in on one portion will only cause the balloon to bulge out elsewhere. It would be a mistake to assume that our healthcare challenge would be fixed by just getting providers to reduce their prices.

More open price comparisons and a more straightforward pricing mechanism are two important elements in successful healthcare reform. With only some exceptions, providers (physicians, hospitals, drug companies, tech companies) are not looking for ways to extract more money from patients. They are taking steps to survive in a broken marketplace. Changing public attitudes about appropriate care, changing insurance to give patients more exposure to their decisions and choices, giving providers incentives to prescribe cost effective care, opening scope of practice laws to let well-trained but less expensive professionals provide some care, and maintaining vigilance over abuse of the patent and malpractice systems are all important steps to take.

 (via IBMLabs)

IBM is enlisting some of the company’s leading scientists and technologists to help medical practitioners and insurance companies provide high-quality, evidence-based care to patients. As part of this initiative, IBM is collaborating with clinicians in numerous medical institutions and hiring medical doctors to work alongside its researchers to develop new technologies, scientific advancements, and business processes for healthcare and insurance providers.