Information provided by Health Train Express and Digital Health Space is informational only. We do not endorse specific solutions. Inclusions are provided as reference only. Readers should consult with their own consultants for further details.

Monday, November 29, 2010

Privacy Matters

Sometimes consumer watchdog and whistleblowers do a good thing (actually they do it a lot).

Several Consumer Advocacy Groups have filed an action before the Federal Trade Commission: “Request for Investigation, Public Disclosure, Injunction, and Other Relief” against none other than:

Google, Microsoft, Quality Health, WebMD, Yahoo, AOL, Health Central, Health line, Everyday Health, and Other web companies, including a litany of consumer oriented marketing scams.

All physicians should be pleased that someone has done this for our patients and the medical profession.

The motion requests that the Food and Drug Administration investigate these sites

The plea includes as one portion of its plea the following,

Physicians, nurses and other health professionals are also the target of powerful digital marketing practices that have a direct effect on the health and financial costs born by consumers. The growth of online “e-detailing,” “e-samples,” and other digital ad practices designed to influence health professionals to order specific pharmaceuticals and treatments raises new concerns over the role of online advertising in the healthcare arena. Data collected via e-detailing and related methods also pose privacy concerns.


The FDA held two days of hearings in November 2009 on the role of the Internet and marketing for regulated drugs.6 Pharmaceutical marketers purposely painted a sanitized, storybook image of social media and digital marketing. Missing were data and information related to the powerful capabilities of interactive marketing to promote relationships with specific brands, including the ability to foster what has been called consumer “micro-persuasion.” “Direct-to-Consumer Digital Marketing” of pharmaceutical and health-related products requires the FTC to develop safeguards for sensitive-data-related advertising practices, and also ensure that interactive ad techniques are truthful and non-misleading.

The pdf file is well worth the read.  This action required a good bit of research to develop a credible request for an injunction Tags: ,,,,

Wednesday, November 24, 2010

The Physick Story


Take a trip on Marketplace  and visit City Hall, The Print Shop, The Surgical Amphitheater, The home of George Guild, the Oculist


Philadelphia: The Birthplace of Healthcare

How did Benjamin Franklin help launch the pharmaceutical industry? How did Philip Physick, who invented dozens of early surgical instruments, also invent an economic instrument that enabled surgeons to get paid? And how did an idealistic eye doctor at the turn of the century help launch what's now a multi-billion dollar screening industry?

Early Philadelphians transformed the money side of health care. It's too fantastic a story to bring you with radio alone -- so health care reporter Gregory Warner and intern Mara Zepeda corralled Philadelphia artists, actors, historians, botanists and puppeteers to help tell the tale. More Marketplace Money Philadelphia coverage »

It is quite a story.

Hear this story how Dr. Physick influenced medicine. The first cataract operation in America, first stomach pump in America, first human blood transfusion, double mastectomies, funded indigent care by selling tickets for the public to watch surgeries.  (A new business model ). 

He offered a prepaid plan for  $20.00 a month.  He became the richest doctor in Philadelphia.

1900. Atlantic City. The American Medical Association — 50 years old at the time — meets for its annual conference. There, a Philadelphia eye doctor named George M. Gould sells doctors on a new idea: patients with no symptoms coming into the doctor's office once a year for a full-body check up. The "annual physical exam" redefines the doctor's role from one who treats the sick, to one who watches over you when well. "It is in catching sight of the earliest indications of disease, the symptom of the symptom," Gould tells the crowd. "That's where progress lies."

Start Video

Hear about the birth of the annual physical

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A Moment of Silence for Tom Turkey


Health Train Express is almost to the TurkeyDepot.  I won’t be posting until Monday, November 29,2010.

I leave  you with this thought.

A Poem  for Thanksgiving


Thanksgiving Friends

Thanksgiving is a time
For reviewing what we treasure,
The people we hold dear,
Who give us so much pleasure.

Without you as my friend,
Life would be a bore;
Having you in my life
Is what I’m thankful for.

By Joanna Fuchs

Belly Stuffer

Thanksgiving brings a terrible chore,
'Cause I’m forced to eat and eat some more.
If I don’t eat it up right down to dessert,
I fear the cook’s feelings will surely be hurt,
So I do my part, even though I suffer;
To be a good guest, I’m a belly stuffer.

By Karl Fuchs

If you wish to learn more about the authors of these poems (two incredible people click on the “ A Poem for Thanksgiving

Tuesday, November 23, 2010

Why We Do Need Or Do Not Need HIT Or EMR


Bad Fonts         Font you

Some of us may remember college, med school, and post graduate training.  I remember my handwriting deteriorating in medschool as I attempted the losing battle of taking hand written notes.

I also remember looking forward to the progression of chart notes and the time when I would write that last note, below.

There is no justice in this world!



EMR will have a profound negative effect on medical students, by reducing motivation to become an attending.

For those interested trainees you can obtain “bad handwriting font” for  EMR notes.

Health Train Express LTE 4G

G et what you pay for

G et better quality

G et government out of health care

G et more primary care physicians

Next will be:

G et EMR

This is what Health Train needs.  Perhaps this will cure what ails health care in America

The Christmas Gift we all Wish for.


Don’t we all wish it could be this simple?

Important News Today Top Stories


FDA Approves New Stem Cell Line

Advanced Cell Technology (ACT), of Marlborough, Mass., announced that it has received FDA approval to begin treating children with Stargardt's macular dystrophy using retinal cells derived from ESCs.

(Photo: A fluorescent microscope image shows human embryonic stem cells at Stanford University  March 9, 2009/California Institute for Regenerative Medicine)


Eat Your Fruits and Veggies

HHS Releases New Insurance Rule


HHS Releases Final Medical Loss Ratio Regulations


So Long, Darvon and Darvocet: FDA Requests Pain Meds Be Pulled



Non invasive Fat Removal


Has The Obama Administration Created a Monster

Monday, November 22, 2010

Accountable Care, or Count the Care?




The consolidations have started. Humana announced it will purchase Concentra. Humana has been a health insurance carrier. Concentra, a privately held health care company based in Addison, Texas, delivers occupational medicine, urgent care, physical therapy and wellness services from more than 300 medical centers in 42 states. The transaction involved a cash price of 790 million dollars.Concentra earns about $800 million in annual revenue. Humana projects that the acquisition will add slightly to its earnings for the year ending Dec. 31, 2011. For Humana, the deal signals that the health insurer is branching back into its origins as a health care provider, but the new business would still amount to just a fraction of its overall revenue.

Humana entered the health insurance segment in 1984, and was a combination managed care and hospital company until 1993, when the company split in half - resulting in a hospital company and today's Humana. The hospital company was later sold.

"This builds on our caregiving heritage and offers new opportunity in a growing part of health care," Noland said in an interview. "The demand for primary care services will increase partly as a result of demographic trends, notably the aging of baby boomers, and also because of some of the incentives in the new health reform law."

Concentra, a privately held health care company based in Addison, Texas, delivers occupational medicine, urgent care, physical therapy and wellness services from more than 300 medical centers in 42 states.    Besides its medical center locations, Concentra also serves employer customers by operating more than 240 worksite medical facilities.

Humana spokesman Tom Noland said the deal announced Monday moves the company "into promising new territory." Humana already operates a few clinics in south Florida.

More than netting immediate financial gain this may signal the first major merger  stimulated by forecasts of  “Accountable Care Organizations”.

Humana’s previous experience with HMOs and managed care gives it previous experience in regulating health costs.  Then again this may fail just as HMOs failed to develop into what was  projected, and rejected by physicians. 

Sunday, November 21, 2010

ACOs Junk-it


The latest round of junkets for hospital administrators, management consultants, is regarding ACOs or Accountable Care Organizations. Like managed care which became renamed “mangled care”  ACOs will earn a new moniker soon as well.  I will rename it, “Anonymous Care Organization” for want of a better term. 

Who is going to run this ‘entity’ designed for who knows what? Some say it will control cost, improve outcomes, and balance the federal budget.   Some say our country will not survive without reducing the percentage of GDP utilized  by Health Care.   Health care expenditures have increasedd to somewhere between 16.0% and 17.9% of GDP according to  Market Watch, Time Magazine, and the Center for Medicare Services (CMS)  and other  bean counters. How about fixing health care expense and increasing GDP?  Much of our  problem revolves around poor productivity, lack of manufacturing capacity,  and lack of diversity in the U.S. economy.


Many features of the robust pluralistic features of American economics have gone by the wayside, the milkman, the paperboy, the corner grocery store, bakery, delicatessen, gardener’s (in the form of after-school teenagers, handymen, bookeepers, #2 pencils, yellow legal pads,   Oldsmobile's, Pontiacs, vinyl records, tubes in radios.  Much of our workforce has been moved offshore, outsourced and/or replaced by computers, software, automation,  and technology resulting in fewer productive jobs, and increased unemployment requiring increased entitlement programs and burgeoning governmental morass.


The present situation in health care is not the fault nor cause of economic stress in America.  This dysfunctional and chaotic representation by the body-politic of America diverts us all from finding the ‘cure’.


Friday, November 19, 2010

Medline Plus Connect


Sometimes paying taxes does bring a dividend. One giant time saving feature is being offered by the National Library of Medicine for those physicians who use EMR.

Medline Plus Connect is a free service of the National Library of Medicine (NLM) and the National Institutes of Health (NIH). This service allows any electronic health record (EHR) system to easily link users to Medline Plus, an authoritative up-to-date health information resource for patients, families and health care providers. Medline Plus provides information about conditions and disorders, medications, and health and wellness.

Medline Plus Connect accepts requests for information on diagnoses (problem codes) and medications. NLM has mapped Medline Plus health topics to two standard diagnostic coding systems used in EHRs. When your EHR submits a request to Medline Plus Connect, the service returns the closest matching health topic(s) as a response.

Medline Plus Connect can also link your EHR system to drug information written especially for patients. EHR systems can send Medline Plus Connect a request for a medication code, and the service will return link(s) to the most appropriate drug information

Medline Plus Connect web site offers technical assistance for software vendors to add links to their programs linking them to Medline Plus Connect.

Medline Plus Connect offers several demonstration programs as a sample of it’s operational features.

Take it for a spin. Tags: ,,,,

Tumultuous Friday


From the LA Times:

Reporting from Washington —

The Senate agreed Thursday to postpone for a month a giant cut in Medicare payments to doctors that had been scheduled to take effect Dec. 1.
The bipartisan deal is expected to clear the House, sparing physicians a 23% fee cut — at least for now. Doctors who care for the elderly under the federal program will be paid at current rates until Dec. 31.
But the compromise falls short of the 13-month solution sought by physicians groups and advocates for seniors. Unless Congress passes further legislation next month, doctors will face another massive cut Jan. 1.


' target=_blank>The Rand Paul  Spitzer Debate

Rand Paul vs. Spitzer


Elliott Spitzer pressed Senator-elect Paul about how he would propose to cut the 1.6 trillion dollar deficit. Paul responded that it would take an across the board adjustment. When pressed further about cuts to doctor’s fees and health care in general he responded that doctors should not take a 30% cut alone unless it applied to all federal employees as well. ie, defense, congress, and all federal agencies. Spitzer pressed further asking Dr. (Senator) Paul what his income was last year, Paul responded that was a personal matter, inappropriate, and that he was not about to discuss Spitzer’s previous personal business either.  Paul also noted that his Medicare fees were reduced by 50% already from 1993 until the present time.

Spitzer commented that Paul was ‘filibustering”.

My comments are:  “The Apple does not fall far from the tree” Seems like Ron Paul taught his son well.

Thursday, November 18, 2010

Medicare and the SGR



My apologies, for the next week I will be running the same post to link to twitter and facebook to spread this  urgent message to patients.

As you may know, on December 1st, Medicare physician payments will be reduced by 23 percent if Congress fails to act. If the December 1st deadline passes without congressional intervention,  it will mark the fourth time this year that Medicare physician payments have been cut more than 20 percent. While Congress retroactively stopped these payment cuts on each occasion this year, this uncertainty has made for a very unstable financial situation for surgical practices and for the patients they serve.  
Physicians in all specialties continue to strongly advocate that Congress immediately stop these cuts, but the College needs the grassroots support of Fellows around the country. I urge you to contact your Senators and Representative to stress the importance of stopping these Medicare cuts and reforming the Medicare payment system so all Americans can continue to have access to high quality surgical care.
Please call your Senators and Representative today and tell them to act THIS WEEK to stop the 23 percent cut in Medicare physician payments from taking effect on December 1st. 

Now is the time for patients and physicians together to voice our strongest protests. This proposed adjustment has been scheduled each year for the past ten years, and then postponed each year. Stop the insanity !!


    As your constituent, I urge you to stop the 23 percent cut in Medicare physician payments scheduled for December 1st.

The flawed Medicare physician payment system threatens access to care for millions of patients, especially our nation's seniors and military families. Health care coverage does not equal access to care, and Congress must ensure that patients have access to the physician services they require.

All senators and congressman maintain a web site which includes an email option, subject; and also a telephone number with which to contact them

  For Senators go to and search by state for your senator

For Congressman go to Search by name or district, click on the contact tab and you will be given a choice between email and telephone number.

Wednesday, November 17, 2010

Health Train Express and the impending SGR Adjustment


As you may know, on December 1st, Medicare physician payments will be reduced by 23 percent if Congress fails to act. If the December 1st deadline passes without congressional intervention,  it will mark the fourth time this year that Medicare physician payments have been cut more than 20 percent. While Congress retroactively stopped these payment cuts on each occasion this year, this uncertainty has made for a very unstable financial situation for surgical practices and for the patients they serve.  
Physicians in all specialties continue to strongly advocate that Congress immediately stop these cuts, but the College needs the grassroots support of Fellows around the country. I urge you to contact your Senators and Representative to stress the importance of stopping these Medicare cuts and reforming the Medicare payment system so all Americans can continue to have access to high quality surgical care.
Please call your Senators and Representative today and tell them to act THIS WEEK to stop the 23 percent cut in Medicare physician payments from taking effect on December 1st. 

Now is the time for patients and physicians together to voice our strongest protests. This proposed adjustment has been scheduled each year for the past ten years, and then postponed each year. Stop the insanity !!


    As your constituent, I urge you to stop the 23 percent cut in Medicare physician payments scheduled for December 1st.

The flawed Medicare physician payment system threatens access to care for millions of patients, especially our nation's seniors and military families. Health care coverage does not equal access to care, and Congress must ensure that patients have access to the physician services they require.

All senators and congressman maintain a web site which includes an email option, subject; and also a telephone number with which to contact them

  For Senators go to and search by state for your senator

For Congressman go to Search by name or district, click on the contact tab and you will be given a choice between email and telephone number.

Tuesday, November 16, 2010

A Look Down the Road at Medicare Cuts

Moody’s Investor’s Report:

Doctor, your credit score will suffer. You will freeze plans for investing in capital assets, personnel, EMRs, and new equipment leases.

There will be multiple and extended domino effects triggered by health insurance reform. I do not believe anyone should call the APPA health care reform.  It is clearly not so.

Medicare pays more than $300 billion to providers annually, covering the care of more than 40 million Americans. About 70% of corporate health providers rely on Medicare and Medicaid for more than one-third of their revenue.

Certain industries stand to face the sharpest cuts in government money, Moody’s says, namely home health, as well as oxygen and durable equipment companies. Hospice care, nursing homes and specialty hospitals are also expected to lose millions off what they receive now. Moody’s says we can expect consolidation in health industries, as providers acquire different health-care entities to diversify.

The entities less likely to face severe trims: inpatient hospitals, contrary to what hospital associations and most CEO’s complain about. Moody’s buttresses their point with a list of for-profit hospital entities that have been assigned stable outlooks. The report doesn’t measure what these cuts might mean for already struggling nonprofits.

  • What and Who They Won't Cut wrote:  commentary from the WSJ article.

Due to massive inflows of corporate cash into the offices of our Congress People the Following Hundreds of Billions of Dollars of Competition Killing Direct and Indirect Government Subsidies will Never Be Cut or Taken Away from the Insurance Companies….

1) Medicare Part D subsidies for insurance and drug companies.
2) Medicare Advantage subsidies for insurance companies.
3) A Federal ban on Medicare Insurance Bidding on a drug formulary through competitive bidding.
4) A federal exemption for private health insurance companies from antitrust regulations allowing them to collude against patients, doctors and hospitals.
5) A ban on Federal grants to develop a single EMR and billing system for physicians, hospitals and therapists which would reveal clinical, preventative and surgical outcomes. Outcome revelations would crush the health insurance companies, and allow for free-market competition among doctors and hospitals based on quality and efficiency.
6) Continued protection of private health insurance companies from medical malpractice lawsuits via federal ERISA laws.
7) Continued reckless and negligent medical rationing by private health insurance companies via their non-physician employees.
8) A continued government ban on collective bargaining by physicians.
9) An inability of Medicare to enlarge its limited risk pool beyond that of the most expensive oldest, sickest and most physically disabled citizens of our nation thereby insuring the bankruptcy of our most effective and least rationed health insurance product for the elderly.
10) A continued allowance of 1.25 million personal bankruptcies due to a medical illness.
11) Continued real change in malpractice reform. Real malpractice reform would allow internists and family practitioners to fulfill their role as primary care physicians efficiently and productively, tackling dynamic illnesses without prematurely referring their sicker patients to expensive specialists without medical benefit.

So what, in typical corrupt government fashion, the higher powers of our bribed public officials have declared war on oxygen vendors, super specialty hospitals, home health, durable wheelchair and bed equipment companies, those who comfort the dying in hospice care, and those who care for the senile and feeble in nursing homes. Moody’s says we can expect consolidation in health industries this is to be expected…bigger insurance companies protected from collusion/anti trust laws, and ever shrinking quality of care due to health care rationing by insurance companies for bondholder and shareholder and executive benefits.

Shame Crying face

Monday, November 15, 2010

Statistics From United Nations International Health Organization


It seems there is a serious discrepancy being bandied about by our health reformers.  In this report from the U.N.I.H.O. their proclamations about quality and availability of health care in the United State do not match these statistics

A recent “Investor’s Business Daily” article provided very interesting
statistics from a survey by the United Nations International Health

Percentage of men and women who survived a cancer five years after diagnosis:
U.S. 65%
England 46%
Canada 42%

Percentage of patients diagnosed with diabetes who received treatment within six months:
U.S. 93%
England 15%
Canada 43%

Percentage of seniors needing hip replacement who received it within six months:
U.S. 90%
England 15%
Canada 43%

Percentage referred to a medical specialist who see one within one month:
U.S. 77%
England 40%
Canada 43%

Number of MRI scanners (a prime diagnostic tool) per million people:
U.S. 71
England 14
Canada 18

Percentage of seniors (65+), with low income, who say they are in “excellent health”:
U.S. 12%
England 2%
Canada 6%

I don’t know about you, but I don’t want “Universal Healthcare” comparable
England or Canada .

for more information

Some criticism may be valid as to the origins of these figures. (see commentary)

Health Reform for Idiots, or Chicken Soup for Health Reform

I found a very nice simple animated explanation which distilled 1200 pages of the Health Reform Act.

A terrific little animated video created by the Kaiser Family Foundation surfaced today, explaining in layman's language what's in store for us with the recently passed Health Reform Law.

Narrated by the wonderful Cokie Roberts, this video attempts to simplify the vastly complex law, with the emphasis on those portions of the bill that impact us as regular folks and as healthcare providers.

Saturday, November 13, 2010

What does the Border have to do with Accountability?


as Posted on The Health Care Blog

Does This ACO Thing Really Mean We Need to be ‘Accountable’?


Kuratis Last month The American College of Physicians (ACP) released a well-reasoned and thorough position paper, The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practicesalt.

As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.

The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.

A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.

However, there’s a great big CAVEAT buried in the position paper.  I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules:

At this time, implementation of the above principles within care coordination agreements represents an aspiration goal…

The care coordination agreements should be viewed solely as a means of specifying a set of expected working procedures agreed upon by the collaborating practices toward the goals of improved communication and care coordination — they are not legally enforceable agreements between the practices. [emphasis of “solely” is in the original document, not added]


Don’t expect to hold us accountable….and don’t expect to be able to sue us if we don’t get it right

Virtual Immigration Fence Failure – A Lesson for Medicine?  from Medical Innovation Blog

imageRichard Reece, M.D.

As Americans, we believe “virtual surveillance” techniques, drones over Pakistan, orbiting spy satellites, cameras on street corners and in stores, telemonitoring of patients with chronic disease with implanted sensors, e-ordering systems to control utilization of high tech medical technologies, virtual integration of doctors and hospitals to reduce care fragmentation – will make us more secure and healthier.
This may be, but we need to understand better what’s taking place on both sides of the technology fence.
The Techno sphere Versus Boots on the Ground
Technologies, no matter how sophisticated, can never replace boots on the ground, humans on the frontlines, police on the streets, or the human needs of populations you are trying to deflect, defeat, control, or serve.
The Virtual Arizona Fence
The “virtual failure” of the “virtual fence” on the Arizona border is the latest example of surveillance technology limits. This “invisible” fence, consisting of strategically and periodically placed high tech radar towers equipped with state-of-the-art monitoring gadgets has failed to stem the tide of immigration. Where there’s a will, there’s a way around the fence.
After 4 years of effort, construction of 50 miles of fence over the 2000 mile Mexico-US border, and a $1 billion contract with Boeing, the Obama administration is abandoning the fence.
High winds, tumbling tumbleweeds, weak cameras, slow software, blurry images that confuse cars with humans, and determined immigrants in search of a better life have combined to circumvent the fence.
In the words of a New York Times editorial,
“The ‘virtual fence’ was a misbegotten idea from the start, based on the faulty premise that controlling immigration is as simple as closing the border — and that closing the border is a simple matter of more sensors, more fencing and more boots on the ground. So long as there is a demand for cheap labor, a hunger for better jobs here, and almost no legal way to get in, people will keep finding ways around any fence, virtual or not.”

The Lesson

For information technology enthusiasts and for those who monitor patient health behaviors through web-based “consumer empowerment” techniques or “physician improvement” technologies, there is a lesson to be learned here.
You cannot control human behaviors at the level of patient-doctor interactions no matter how “sophisticated” your data mining or monitoring efforts. And you cannot do it without more “boots on the ground,” more physicians in the clinical trenches to critically appraise human needs, to prevent “immigration” towards bad health and high cost hospitalizations.  (underline mine) High tech fences will not keep immigrants out of the human garden. And you cannot weed the garden using high tech information sensors.

Posted by Richard L. Reece, MD at 12:24 PM

Friday, November 12, 2010

Future of Health Reform


Today on CSPAN the Robert Wood Johnson Foundation presented a summation of the current environment in congress and future possible modifications to the health reform law.

Dean Rosen, former assistant to Bill Frist, MD, the former speaker of the house, Norman Ornstein, resident scholar at the American Enterprise Institute, and  Ed Howard, from the Alliance for Health Reform each give their expertise on current events.


Thursday, November 11, 2010

KevinMD hosts Health Train Express


Just a pat on my back (spraining my shoulder) and a thanks to KevinMD for hosting Health Train tomorrow—Friday.

Wednesday, November 10, 2010

Politicians know S %@*t about Health Care


A good friend and colleague sent me a link to a video.  I advise you that there is a lot of foul language in it.  I thought it was outrageously funny and exactly on point.  When I thought hard about it I thought, What the f#%!k .  If Obama doesn’t understand it or get it by now he never will). 

Thanks again to Xtranormal,  the do it yourself  internet Pixar of the  21st Century.


The White House Oval Office


One of our problems as physicians is that we rarely say no, or go to h#@l!  We are always so reasonable and accommodating, while we slowly are boiled.  So I don’t believe I need to be polite, or politically correct or even have good manners.  I and most of my colleagues have been wrung out and demeaned beyond belief. 

You will all think I have lost it, and I am ready to hear that as well. But the AMA and the rest of it have not done any better kissing a@s,

and pouring $$’s  into the cesspool we call congress. Tags: ,,

Cleaning up The Health Train Express


In an effort to speed up loading the landing page of my blog I have deleted many links, ads, and unnecessary ‘noise’.  Hopefully this will speed up your access, reduce internet traffic between sites.  This is my effort to make the internet more green.  For the time being I have left the blog links alone.

I will be playing with the overall design in the coming week. Anyone who has a strong feeling or opinion can leave a comment.



Video Game and Butchers, What do they Have in common?


The '” boys “  over at  The Healing Blade  and  Nerdcore Learning bring new multimedia strategy to the healing arts.

Turn on your wide screen HDTV and get your controllers ready!


Those  long hours in the video game room may be paying dividends in learning as well as improving surgical skills.

The Butcher does not have to code, the surgeon does, butcher does not need malpractice coverage, no CME, not on call, does not need hospital privileges.   If you like to cut, be a butcher.

Monday, November 8, 2010

Health Train caught in an Earthquake???



Hospital Seismic Safety Report  February 2010


We all know about the seismic risks to buildings in California, including health care facilities.  The California Healthline recently  reported the summary information available as of November 6, 2010.

Unfortunately, although mandates for seismic retrofit was established many years ago, the vast majority of hospitals have not been officially evaluated for potential collapse in a major seismic event.

California does not require hospitals to determine their collapse risks, but facilities can do so voluntarily. Hospitals also do not need to determine collapse risks for each of their individual facilities, making it difficult for some hospitals to determine which building to retrofit first.


Efforts To Assess Risk

In 2002, California compiled a list of 1,100 hospitals that could pose a risk of collapse during an earthquake. Of those, the state conducted complex evaluations of 370 hospital buildings and determined that 280 facilities had low enough collapse risks to qualify for the 2030 seismic safety deadline.

State authorities now are focusing on about 700 hospital buildings that were placed in the highest-risk category.

Of those, the state has determined collapse risks for only 90 facilities. Fourteen of those 90 facilities have been assigned collapse risks of between 10% and 32%, far higher than the 1.2% collapse risk that officials deemed reasonably safe.


 A map showing the location of hospitals with buildings that have a 10 to 32 percent chance of collapsing in an earthquake. Click on this link to see more information about the 14 buildings located at these hospitals.

What's left are about 700 hospital buildings in the highest-risk category that still face deadlines to make changes. Officials only know the collapse risk for about 90 of those buildings, which range from .75 to 32 percent.

Medicine from 40,000 feet


Way back in the mid 20th century when I graduated from George Washington University with an M.D. degree I imagined that I had “arrived”.  I remember my classmates selecting different specialties and eventually going off to clinical training. I could not imagine doing anything other than clinical work, and perhaps dabbling in some clinical research.  Some of my friends were studying ‘epidemiology’ and a new field ‘public health’.  At that time, it mostly  was dedicated to ‘epidemics’, vaccinations, preventive medicine, and things that to me did not really involved patient care.

Turn the page, 50 or 60 years. This specialty has morphed into having an MPH (Masters in Public Health), and perhaps an MBA in health administration..  Previously these professionals had little to do with your clinical practice on a daily basis.  Now these people are the groundbreakers, movers and shakers throughout the medical world in which we all practice.

My school is now known as “ George Washington University School of Medicine and Health Sciences. The previous formal division of Medical Clinical pursuits from allied health and health business has become blurred at the educational level.  This blurring of distinction has also occurred in the clinical world with PAs. NPs, Advanced Degree nursing specialties and the like.

As a delayed and recent student of this field , and as a result of my blogging research I see that the topography has changed drastically.  Previously treated with disdain, MPHs, and MBAs, and MHAs increasingly have invaded our insular clinical world.  Many health reformers and policy makers delved deep into the social psychology of medical practice, medical group organization, quality measures, and even reimbursements.  All of this has evolved into an environment of MPHs having a huge influence on governmental policy makers.   Many MPHs have evolved into a new specialty of Political Influence.  Many practice medicine, not by treating patients or treating diseases, but by spreadsheets, algorithms, and formulating treating diseases from 40,000 feet….far removed from the implications of their edicts.


The flack is coming from we clinicians on the ground.

Gee, I wish I had gotten that MPH.

Sunday, November 7, 2010

Disruptive Luddites


For Ophthalmology Times:

The past year has seen a rapid acceleration and implementation of electronic medical records in medical practices. While some ophthalmologists long ago installed EMR it was for the reason of establishing a reliable medical record, and also to improve the efficiency of their practices, improve reimbursement and eliminate paper. Most ophthalmologists lagged in EMR usage due to lack of affordable solutions and the fear of disruptive technology.

During the second and rapid phase of adoption of new technology we have gone beyond 'early adopters', and the remainder of ophthalmology is adopting for political/financial incentives or social influence. Social influence plays a large role in the selection process of the EMR. Ophthalmologists and many physicians rely upon social medical peers for their demonstrations and testimonials regarding EMRs.

Like it or not in the next two years most of us will have adopted EMR and HIE (health information exchange), and not for just financial reasons. Instead of investing in that 4th generation OCT, or Wave front analyzer you will opt to buy an EMR, for which you will be at least partially reimbursed. (and most likely more than a charge for an OCT or Wave front calculation. The smart money will go toward EMRs. In most specialties the reimbursements are being bundled, and the ROI or recapture of investment will be much less than the incentive for purchasing an EMR.

We will increasingly see that referral sources require electronic communication with specialists, and will expect consultation reports to be sent electronically, via the health information network(s). This will take some time to establish, but it is inevitable.

Like my analogy on the Health Train Express....move over or get run over! It is a bit like the negative effect of not adopting a disruptive technology. By not adopting a growing technology you will be at a disadvantage in the market place, which will more than disrupt your practice than if you had adopted EMR.

John Hamlaka MD, who is the CIO at Harvard makes the following observations.

“The ONC is concerned about the success of meaningful use Stage 1, “and if it turns out much of America can’t achieve meaningful use Stage 1, then more rigorous criteria are not a good idea,” he said. The ONC is expected to further refine the requirements and do a second-quarter 2011 checkpoint to see how it’s going.
Stage 1 programs start in January, attestation will begin in April, and the first incentive dollars will be awarded in May, Halamka said. “The implication for many of us is that you better make sure you have the capacity to do all these quality measures January through March, 2011.

“In some ways, quality measures as they exist are process measures,” said John D. Halamka, MD, during his closing keynote HIMSS Virtual Conference presentation.

Stage 2 will see the introduction of outcomes orientation, and Stage 3 will move to outcome measures, which measure the wellness of a patient instead of how many tests were ordered for a given patient, said Halamka, an emergency room physician and CIO of Beth Israel Deaconess Medical Center and Harvard Medical School, chair of the U.S. Healthcare IT Standards Panel (HITSP) and co-chair of the

Saturday, November 6, 2010

When Do We Get to The Next Stop?


Did I miss my station? 

I’ve been riding the Health Train Express for several years. I seem to have missed many stops and find myself at the end of the road. Somewhere in between I have vague recollection of stops along the way,  SGR, HMO, PPO, IPA, PQRI, ARHQ, CMS, HITECH, PACA,NHIN, HIE. EMR, RHIO,HHS.

What does it all mean?

Jane M. Orient, M.D., is an On Air contributor speaking on Healthcare Reform. Dr. Orient has appeared on NBC, MSNBC, ABC and many major broadcast venues throughout the US, as well and her Op-eds have been printed in hundreds of local and international newspapers, magazines and followed on major blogs. She has been in solo practice of general internal medicine since 1981 and is a clinical lecturer in medicine at the University of Arizona College of Medicine. She received her undergraduate degrees in chemistry and mathematics from the University of Arizona, and her M.D. from Columbia University College of Physicians and Surgeons. She is the author of Sapira’s Art and Science of Bedside Diagnosis; the fourth edition has just been published by Lippincott, Williams & Wilkins. She also authored YOUR Doctor Is Not In: Healthy Skepticism about National Health Care, published by Crown. She is the executive director of the Association of American Physicians and Surgeons, a voice for patients’ and physicians’ independence since 1943. Complete curriculum vitae posted at Additional information on health-related issues: and

Congress handed the Congressional Budget Office (CBO) some assumptions, the computers came up with the mix of adjustments needed to give a magic number under $1 trillion in 10 years, and the “Affordable Care Act” (ACA

Numbers are thrown about—but where’s a spreadsheet of the money flows? The President couldn’t exercise a line-item veto even if he had one because there aren’t any line items. For example, how can you budget for each of the new bureaucracies if you don’t even know exactly how many there are (159—more or less)? And are they counted in the $1 trillion cost?

This article by Dr Orient succinctly elaborates the incompetence of the ACA (Affordable Care Act) as she writes in The Health Care Blog.  It seems to have been written by a legal intern skilled at legalese without thought about a strategy for implementation. Each section is written with the assumption and without regard for the effects of a prior change in the health care system.

Her summation is chilling, and should be read by every American and our congressional representatives,  who should have read the bill before voting it’s approval.

PACA needs to be repealed and/or amended drastically. Let’s not give up and roll over.  Change is what he wanted, and change is what we will give  Obama.

Wednesday, November 3, 2010

Election day Aftermath

Here we are one day post election.  It was reported that 1.6 billion dollars was spent for the benefit of politicians and free spending businesses, lobbyists, and some well meaning citizens who buy into their lies, promises and grandiose ideology and plans for the republic. No doubt many of these companies, and individuals had some self serving sinister motives. Campaign financing laws are easily thwarted,  to attain these levels of spending a mid-term election.  There is a great deal of American Wealth at stake, your wealth as our politicians fight to obtain your money for their purposes, without regard as to whom elected them or pay their salaries. Media companies  flourish from our largesse,  disseminating half trues, and opinion, competing for advertising dollars and ratings.

“Take back our country”  should be re-stated as “Take back our Money”

I have always  been a moderate, paid taxes, contributing as much as I could when I was relatively well off, employing ten people, accountants, attorneys, insurance companies, not only for malpractice, but liability, disability, health insurance and more. I fueled several medical technology companies for diagnostic and surgical equipment as equipment became obsolete every five years, or less.  I created a ten year business plan investing a significant amount in equipment with a depreciation plan. 

All of my  planning and budgeting were sabotaged by the ‘threat of inflation’ and the projected insolvency of Medicare. During the late 1980s and early 1990s a plan was developed by some ‘hidden magical gurus of health care planning’ located within the D.C. Beltway.  HMOs, IPAs, Managed Care, PPOs and other eponyms were launched with the objective and promise of ‘cost containment’.

It is difficult to prove a negative but one naturally questions what would have occurred if these changes did not occur.  Medical care and the quality of care suffered greatly, administrative expenses soared with the multiple tiers of billing, review and organizational expense.   New positions were created for ‘executive directors’, added administrative expense and consultants in management. Most patients and physicians despised the system.

We were paid less, buying into the concept of ‘withholds’ which would be paid back if doctors managed well and thereby receive a rebate.  I witnessed one of our organizations hi-jacked by our board, using our funds to capitalize the  organization to sell it to Aetna’ managed care plan. This company and many others like it removed much of our income which formerly covered operating expenses and allowed for charity care for the uninsured, both in our private offices and hospitals. Whether there were cost savings remains very much open to question. Many of these organizations merged, failed or became insolvent. 

The  true definition of insanity is to repeatedly do the same thing, resulting in a bad outcome and then repeat it expecting a different outcome.

Our entire medical system has been manipulated and re-organized with devastating outcomes, the number of uninsured has soared, as government has become more involved in the process.  Rest assured our elected officials will fail to control their mandates for ‘Obama Care’.  That is evident from the law they passed without reading or understanding the full implication of the law.  They certainly did not plan the secondary or tertiary effects of the law and how insurers, employers and patients would “gain the system.”

Think about this…40 million citizens (and perhaps a fair number of undocumented aliens receive food stamps to survive. Some of them drive gas guzzling SUVs which have become less expensive to buy because others cannot afford these vehicles to drive to and from work any longer. (Another unintended consequence of a well meaning mandate for fuel economy and “green”. So the poor non working and some disabled can afford better things that hard working employed who have significant other cost of living expenses from their ‘declining spendable income.”

Not mentioned is the tremendous increase in cost of regulating and enforcement of these new laws. 

While you and I have little time to devote to being a ‘watchdog’ over administrators , politicians, we are paying their salaries to got to meetings to plan our destruction, not only of the earners  but the people’s freedoms who receive the ‘rearrangement’  and re-distribution of your property and wealth.

The election illustrates that physicians themselves are still trusted by the people.  Several physicians, one of whom is Rand Paul, MD (an ophthalmologist) were elected to the U.S. Senate. And despite being ridiculed by other candidates, and even some physicians his message rang true for the people of Kentucky. 

The forgers of our constitution were very brilliant in codifying our country’s foundational concepts.  Those concepts brought us through many crises, and it should not be decimated by “ convenience to businesses, decision makers, nor Presidents. It has already been significantly degraded and is in danger of being destroyed. 


Our republic was formed with the ability to reform itself through legal process codified in the US. Constitution.  Our peaceful  transition of ruling and power is peaceful despite significant and deeply entrenched diverse values of our peoples.

As long as these values of our legal citizens are respected as we move forward things should continue to flourish despite our current

difficulties. The Constitution was created for our present contingencies as an eternal document to be built upon ,just as the Magna Carta, and the Bill of Rights have served as part of our republic.