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

I’ve come across few articles recently that really validate the notion that the success of healthcare IT is really in the eye of the beholder, or in some cases, the editorialized results of a study.

Take, for example, the following headlines:

“EHR Use Not Linked to Improved Diabetes Care Quality, Study Finds”
and
“App Improves Diabetes Management Among Teenagers, Study Finds”

I find it hard to believe that if formally connected, the second study couldn’t somehow influence the first. In other words, if a mobile health app can improve diabetes management among teenagers, shouldn’t whatever data that app is capturing transmit successfully to the teen patients’ EHRs for easy access by their doctors? And then couldn’t that doctor digest that information, picking out patterns in the patient’s behavior that is either positively or negatively impacting their diabetic condition and overall health, to better inform care protocols?

I’m taking big leaps of logic here, since the first study found that not only was there no correlation between the use of an EHR and “increased adherence to clinical guidelines for care processes and treatments,” but there was actually a “higher probability of meeting certain targets for blood pressure and A lc levels after two years” at practices without such systems. (Seems like these outcomes might be due more to end-user experience than the technology itself.)

The second study doesn’t even mention EHRs, but I wonder how many of the 20 teens participating in the study see doctors who have this type of technology, how many of those doctors know their patients are participating in the study (all I’d assume), and how many are feeding the app’s info into an EHR.

Surely if a smartphone app is helping a diabetic teenager better adhere to medication regimens, then the EHR their doctor could potentially be using would somehow tie in to better clinical outcomes. Another study to start, perhaps?

The second set of headlines that gives me pause (and kinda makes me chuckle) includes:

“Physician Use of Tablets has Nearly Doubled Since 2011”
and
“Not all Doctors and Nurses are Happy with an iPad in the Hospital Setting”

Neither headline surprises me. We all know that adoption of mobile health tools is growing, if not by leaps and bounds then at least steadily. It would make sense that providers are adopting tablets in relation to this. Every technology has its detractors, so of course not everyone is going to be happy with how an iPad works in a clinical setting, just as not every provider is going to want to install an EHR. I do wonder, though, how the same set of users mentioned in the second article would rate a different kind of tablet if given the opportunity to use one.

I find the first sentence to be kind of hard to believe: “It looks as if most doctors and nurses would rather not touch the iPad at work (or deal with any other kind of tablet computing).” If “most” doctors and nurses would rather have nothing to do with tablets at work, than how can physician use of tablets have doubled since last year?

So you see, the “success” of healthcare IT seems to depend on whose writing about it. I have a feeling the American Forest and Paper Association might be behind the very first one.

Related posts:

1. Will Rip and Replace EHR Software Ever Be a Thing of the Past?
2. Emdeon Gets in the Holiday Spirit with Donation of EHR Technology
3. From the Trenches of Healthcare IT Education

I’m in Boston enjoying meeting with a lot of really smart people at Health 2.0. As usual, the biggest value of the conference is the people you meet and the hallway conversations you have with those people. I’ll certainly be doing posts over the next couple weeks related to those conversations.

The other highlight of Health 2.0 was hearing Jonathan Bush speak. He was in true Jonathan Bush form and he’s great because you can guarantee that he’ll never give the same speech twice. As one person said in the hallway, the connection between him thinking it and him saying it is very short. It’s so short that it has no filter. My biggest complaint with Jonathan Bush’s talk was that they only gave him 20 minutes on stage. Not nearly enough.

For those who couldn’t make it, here’s the main points that Jonathan Bush provided:
1. “Don’t bite off more than you can chew.”
2. “You need your partner’s ‘id’ as well as their signature.”
3. “Culture trumps capability.”

This is all really good advice for healthcare startup companies. One other thought from Jonathan Bush:

.@Jonathan_Bush compares entrepreneurial survival to paramedics’ attention to the ABCs…focus on first things first. #health2con #EMS

— Carissa O’Brien (@CarissaO) May 15, 2012

Here are some other good takeaways from Health 2.0 Boston that were tweeted out:

Steve Krein: Introductions are easy, being prepared for the meeting and what follows is hard #health2con

— Matthew Holt (@boltyboy) May 15, 2012

Very good advice and appropriate at Health 2.0 Boston since the focus of it is about partnerships.

The core problem is “uncompensated care.”#health2con

— EMR, EHR and HIT(@ehrandhit) May 15, 2012

There’s a compelling story if you look at how much uncompensated care physicians provide.

Related posts:

1. It’s Official – I’m Attending the Connected Health Symposium in Boston
2. Digital Health Summit at CES and Stop SOPA
3. A National Universal Health Record (UHR) Database – Doable Any Time Soon?

Over at healthaffairs.org, there was a super interesting brief on Affordable Care Act and its forthcoming changes regarding employee health. Starting in 2014, employers will be able to offer incentives to employees regarding their enrollment in employee wellness programs. Employers can offer incentives such as monetary rewards for positive employee behavior like enrolling in a smoking cessation program, or joining a gym at discounted rates. Or these can work like the proverbial stick, by imposing penalties on non-compliant employees, e.g. increasing the cost of participating in an employer health plan by $1000 for employees who say they have smoked in the last year.

Now all those good components of the ACA will still be applicable i.e insurance companies will not be able to refuse patients based on prior medical history. But I can’t help but notice the irony of the ACA being used to discriminate between a healthy employee and a sick one.

One of the examples cited in the brief is that it will be legal for an employer to offer a health plan to employees who fulfil certain wellness criteria such as enrolling in a gym in addition to the other health plan options available to its other employees. The cost of the other health plan options to a truly unwell employee could well be so exorbitant as to make it impossible for him/her to enroll in it. Options for such employees could be to enroll through a spouse’s plan or purchase private insurance through the health information exchanges. The brief says that there are plugs for these sorts of employer excesses, such as companies with over 50 employees will be penalized even if one employee enrolls in a subsidized state insurance program in lieu of the company sponsored one.

I’m also wondering if there will be any kind of guidelines for companies to design their incentive/penalty programs. Health and wellness are incredibly nuanced issues. For every person who can exercise a half hour a day and lose a pound a week, there are those who seemingly subsist on air and water and barely make a dent in their BMI. Genes determine plenty of factors in a person’s helath profile, including weight, propensity to develop certain conditions and so on. It makes me wonder if we’re oversimplifying things by gauging employee wellness based on criteria such as gym enrollment.

Plus what if you have lots of people like me who might enroll in a gym and never see the inside of it beyond the first few days? Simple enrollment might not be enough. But, to my mind at least, tying enrollment to outcomes has the unfortunate whiff of a mini nanny state in the making. Who wants to be the person at the company weigh-in whose BMI has come down by .1 while the muscled, rippled company health club employee looks at you quizzically? Not me.

I also worry about the unwell employee who feels pressured into signing up for risky activities (from his/her health perspective), simply in order to get the rewards offered or to avoid the penalties. S/he might have something truly tangible to lose both ways.

I would love to see how ACA transforms in the next couple of years but right now I think I have way too many unanswered questions.

Related posts:

1. iPad in Health Care
2. Health Care IT 2011 Predictions
3. Health Care IT at CES

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!

Read More

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.

Read More

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.

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

Do you think your Lab software is the tool you need?

Over the past years, I got the chance of get in contact with many Laboratory Information Systems (LIS) available in the market.

And when I look back, and try to analyse them from a safe distance I get the feeling that they all have more similarities than differences.

They all share some common goals:

• spread as far as posible!!!
• adapt as fast as you can!!!

damn, look like a virus to me!!!

They all try to reach to different types of Labs, try to do different tasks, try to manage different business environments, try to adapt by all means to the circumstances, etc. And to do this they all seem to loose their vertebra.

Sometimes, it is wise to stop and accept that your software is not tailored to manage all the information concerning your lab.

Let me give you an example, a good clinical management software does not have to be a good stock management software.

Maybe your software is great for communications with lab analysers, but maybe it sucks for data mining.

And sooner or later,  the Lab Manager will ask himself why is he carrying this huge, complicated, heavy, not flexible tool, when most of the time he only need a small tool, and only ocasionally he will need ‘the big stuff’.

Surelly he will wonder, “wouldn’t it be nice to modularize my software, use as I need, and hope my ‘modules’ communicate each other nicely?”

Occasionally, every blogger gets into a situation of wondering if he/she should continue to post.

I’ve been in that (in)decisive situation over the past year. Between two house moves, managing family priorities among everything else, this blog has been stalled.

I’ve decided to try to give the blog a new chance.

Hope this is a good decision.

Now that I’m back in the business, I’m trying to keep up to everything that I missed in this last year.

There was a generous reference to my blog, from DarkDaily that I’d like to share with everybody:

“Geek in the Lab
Pedro Fonseca has been an IT healthcare specialist for more than 15 years. It is clear while poking through Geek in the Lab that Fonseca is passionate about information technology as it relates to healthcare. “Geek in the Lab” is laid out so that IT professionals can keep up with the latest in healthcare technology, but it is written in a way that is accessible to the laymen. While many similar blogs are full of difficult to understand technical jargon, Fonseca makes sure his blog is easy for all readers to understand. Far from a “How To” advice column, “Geek in the Lab” keeps track of healthcare IT trends and offers observations on how they may impact the big picture. Fonseca’s “Gadget of the Week” gives readers a glimpse of the latest in IT tech.”

Thanks to Robert L. Michel and his team for such kind words and keep the good work.

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.

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.

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.

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.

The following just came across my Google Alerts:Healthcare Analyst Values MMRGlobal Patents at $300-800 Million. This is scary. I’ve seen this company for years; they were one of the pack trying to build personal health records in the mid-2000s, and from what I’ve seen there is nothing in their historic offering that was particularly innovative – except that unlike most of the others running around at the time, they appear to have had some budget to file some patents, and they have now commenced shaking other people down.

Now, I haven’t done a very complete review of their patent holdings, and they may well have some highly innovative, original work there that took a substantial investment to develop and realize. But that’s not the trend, and I’m very concerned that this could be problematic for a lot of small innovators in the personal and clinical health records markets. Software patents have become a real problem across a variety of domains, but so far HIT seems to have avoided the worst of it. I suspect that this is in part because of industry’s long history – most of the core capabilities were introduced long enough ago that any patents would have expired. There’s a ton of prior art: you can track a lot of personal health monitoring to 1994′s Guardian Angel Manifesto. But that’s expensive to litigate when the trolls come out from under the bridge.

As it stands, I’m looking for defensive patent structures for my own start-up so that we have some chits to trade if someone comes knocking. And that’s a shame – I have better things to do with my time.

Just read a nice summary from OpenView on hiring your first sales manager. This is, far and away, one of the most daunting things that any technically minded startup CEO faces. If you come from an engineering or science background, it’s easy to think of the sales team as, if not actually an enemy, as something a little bit alien. I know a lot of engineers who simply don’t get on people in sales – they regard them either as ineffective suit-fillers who can’t do “work that matters” or as the latest embodiment of the obnoxious popular kid from high school.

Some companies try to get around this by making sales people out of people who aren’t naturally sales people. In the Healthcare IT space, that’s often former nurses or physicians who want a career change. In software, it’s often software engineers. There’s potential in all three groups, but it takes a certain type.

If all goes well, I’ll be going through this process again in the near future. If so, I’ll post what I learn.

Knowing how to code is a really useful skill for anybody in business. For an entrepreneur, it means you can validate your high-tech startup idea without having to out and recruit a CTO or spend a lot of money on an external software development shop. But even if you’re running a pizza place, a little bit of coding experience can save you a lot of time when you’re playing with Excel spreadsheets late at night trying to figure out how much money all that fancy pepperoni is costing you.  Most people are in the middle. I have a lot of friends who went into management consulting – the ones who know how to write little bits of software to help them do their jobs tend to get a lot more sleep at night.

The other reason to learn programming – even a little bit of programming – is that it makes the whole process of interacting with technology a lot less scary. Computers are black boxes, and people don’t trust black boxes.

So I thought CodeAcademy was pretty cool. It’s a web site that takes you through some simple programming exercises in JavaScript, which is one of the most common programming languages on the web. In half an hour you can go from no experience at all to writing simple programs. They don’t do that much, and to solve real problems you’ll have to do more. But it’s a nice way to start out – and even if the student doesn’t go any further they’ll benefit from a more visceral understanding of how computers work. In the best case, it will teach them to recognize the kinds of patterns that can be solved with a little code.

Having written that, I suppose I should consider the opposite extreme. Just because you can write simple programs after half an hour of interactive lessons doesn’t mean that software development is either easy or low-value. It’s not. A top-tier software engineer took thousands of hours to get that way.

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.

 (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. 

Interested stakeholders have submitted their comments regarding the Proposed Rule for Meaningful Use Stage 2. Providers and their professional organizations, vendors and HIT industry associations, and consumer groups advocating on behalf of patients have written detailed—and often lengthy—tomes for CMS and ONC to consider.

Sadly, the overly aggressive nature of the proposed requirements for Stage 2 is pitting providers against patients. Providers, with support from the EHR vendor community, express concern that the bar is being raised too high and too quickly to be practical, while consumer groups argue that we would be missing an opportunity by not raising it even higher. The pleas from both sides are equally passionate and well intentioned.

However, this should not be a battle—the fact that it has turned into one is most unfortunate. I believe that all stakeholders are truly committed to the same goal: higher quality, safer, and more convenient care for patients, provided efficiently and at a reasonable cost. Everyone agrees that meeting these goals requires moving towards increased interoperability and greater patient engagement, but it is the specifics of these requirements—as proposed for Stage 2—that are stirring up the controversy.

We need to advance at a reasonable pace, one that is challenging but not overwhelming. The risk of pushing providers to the point where the requirements are perceived to be unrealistic, unmanageable, and overly burdensome—particularly as incentives dwindle to insignificant levels—is that they will abandon the program as unachievable. If that happens, the continued success of the incentive program will be in jeopardy. No one’s goals will be met.

A very positive conversation took place at yesterday’s HIT Policy Committee meeting, and it put the focus squarely on the physicians—a focus that in the past seems to have gotten lost in the shuffle.

The Committee was reviewing and finalizing its comments for submission to CMS on the Proposed Rule for Stage 2. A healthy debate ensued regarding who should have to enter the orders into the EHR to satisfy the CPOE requirements—the physician or a designated clinical staff member. In response to a suggestion that there were reasons for requiring the physician to personally enter the orders into the system, Neil Calman, MD, raised the discussion to another level by asking about the entire purpose of EHRs and meaningful use. Dr. Calman challenged his fellow committee members to think about how an EHR should be expected to change the way physicians practice—and how it should not. He asked why we would want to bog physicians down with tasks that other staff were already doing instead of helping physicians focus on the work that utilizes their highest skills and expertise.

The EHR incentives are definitely encouraging EHR adoption, but we should not lose sight of why increased adoption is such an important goal. The value of an EHR to a physician is not the $44,000 incentives—it is the potential for increased productivity and efficiency, better and safer patient care, and the ability to share information. It’s easy to get caught up in creating comprehensive measures that ensure that the interests of all stakeholders are met, and in doing so, to lose sight of the practical impact on physicians’ workflow. In the case of yesterday’s CPOE debate, the committee came up with a recommendation that preserves the intention of the CPOE measure—and meaningful use in general—while respecting the value of the physicians’ time. I hope this conversation will set the tone for future meaningful use deliberations.

I was shocked to read the following paragraph, buried on page 379 of the 455-page Proposed Rule for Stage 2 Meaningful Use, (page 13812 in the Federal Register). The paragraph also appears verbatim in the Final Rule for Stage 1:

Explanation of Benefits and Savings Calculations:

In our analysis, we assume that benefits to the [EHR Incentive] program would accrue in the form of savings to Medicare, through the Medicare EP payment adjustments [penalties]. Expected qualitative benefits, such as improved quality of care, better health outcomes, and the like, are unable to be quantified at this time.

While the second sentence is disappointing, I do respect CMS’s candor in acknowledging the ongoing paucity of hard data on the quantification of the assumed qualitative benefits of EHR adoption. The first sentence, however, left me short of breath because it points to the following inescapable, disheartening conclusion: The economics of the EHR Incentive Program is predicated upon physician failure!

In fact, the government’s projections for physician participation from 2014 through 2019 are rather pessimistic. Meaningful use among Medicare EPs is estimated to grow, in the less optimistic (“low”) scenario, from 18% to a mere 36%, and in the most optimistic (“high”) scenario, only from 49% to 70%.¹ Even these high projections are low enough—incidentally—to give the Secretary of HHS the option to increase the penalties from the statutory 3% in 2017 to a potential 4% in 2018 and 5% in 2019.

What kind of program have we created that over a period of 9 years will likely take almost as much money from physicians as it gives them?

The government giveth and the government taketh away!

¹Source: Proposed Rule, Stage 2 Meaningful Use, page 13804, Table 19.

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.