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.

Wednesday, February 29, 2012

Comic book explains, Advocates Health Care Reform


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The health care overhaul is complex. It’s confusing. There are multiple misconceptions about it.

So Jonathan Gruber decided to set the record straight in simple fashion: a comic book.

It’s classified as a “graphic novel,” illustrated by award-winning artist Nathan Schreiber. But it’s not fiction.

In fewer than 150 pages, the two combined their expertise in “Health Care Reform: What it is. Why it’s necessary. How it works.”

The paperback volume is a primer to help people understand — and buy into — the ideas contained in the Affordable Care Act.

There’s no question that Gruber, a professor of economics at Massachusetts Institute of Technology, is an advocate of the changes.

He is director of the health care program at the National Bureau of Economic Research. He was the main designer of Massachusetts’ health care law. The Obama administration consulted him to help construct the national act. He is a member of the Institute of Medicine.

Gruber walks the reader through the situations fostered for each in today’s health insurance climate and explains the financial consequences. Then he presents a case for the changes envisioned by the Affordable Care Act.

Read more here:

Perhaps Congress should have read this before they voted:

Now even doctors can understand the  new law.

Is There an “Oscar” for Healthcare ?



Much like entertainment, health care information will become available on all media. The convergence of many technologies such as Television, cable, internet, smartphones, tablets, desktops and more devices stimulates openness and transparency. The convergence of all these formats is occurring rapidly each year.

We all know as according to Phil Bauman that “Health is Social” Yet why do physicians either recoil or are dismissive about social media?

Tonight I am watching the Academy Awards on an internet live stream with a choice of six different cameras with upfront face-to-face encounters. It’s all in HD. Television still does not yet have the events on live. (5PM PST).

I have four active windows to select from: Arrivals, Grand Entrance, Red Carpet and  Interviews. All windows are in real-time and simulcast.

Who are the  nominees for the Health Care Oscars in 2012 ?


Best use of Health 2.0

Best Electronic Medical Record

Best Social Media Platform

Best mobile application

Best Health Information Exchange

Best Health Insurance Reform Plan

Best Translational Science application

Best genomic discovery an application in healthcare's

Best Health Blog

Best General Medicine Journal

Best Specialty Medicine Journal

Perhaps the Nobel Prize, Woman in Science Award, The National Academy of Sciences Awards,


The Lasker Award

The Elliott Cressen Gold Medal Award, (now a part of The Franklin Institute)

The Alpha Omega Alpha Honorary Society (AOA),

Wolf Prize in Medicine,

Further suggestions are invited @glevin1 or email

Saturday, February 25, 2012

Finding Fraud in Medicare Claims



Certainly one of the methods to reduce fraud is to catch the opportunists that see the U.S. Treasury as easy pickings.  Hidden in the maze of billing, coding, electronic claims is software coding that can easily be turned to the white collar thieves.

As physicians we need to be aware of the potential of careless, negligence and even possible misuse of your own billing system.  The buck stops and starts in your very own office.

Fraud can be construed when a charge is made for a procedure that has not been performed, or with creative 'up coding' to a higher management code. Another common procedure is a 'storefront' phantom medical practice.



Medicare billing errors, excessive payments and fraud have cost U.S. taxpayers hundreds of billions of dollars over the past decade. Medicare's annual estimates, however, do not account for all fraud nationwide.


Federal prosecutors in South Florida scratched the surface of Medicare fraud in the 1990s. But it wasn't until a few years ago that they began to crack down on the corruption. Today the region's prosecutions account for more than one-third of all Medicare fraud cases nationwide.

Read more here:  Miami Herald 


Medicare fraud rampant in South Florida




Whenever Alexander McCray lights up his crack pipe, U.S. taxpayers help pay for his habit.

McCray has defrauded Medicare by selling his government-issued health card number to private clinics in exchange for kickbacks of $150 to $300 a visit -- as often as three times a day, three times a week over seven years, according to federal records and his own admission.

McCray has signed off on phony infusion treatments for his HIV illness -- therapy that is medically obsolete -- and he has received thousands of dollars from Medicare-licensed clinics all over South Florida.

Money that he has used to buy crack cocaine.

Dozens of clinic operators have in turn filed more than $1.1 million in false claims for fabricated HIV-infusion treatments billed in his name, according to Medicare records reviewed by The Miami Herald. Some 90 doctors, including one indicted in May, appeared on the phony prescriptions written on behalf of McCray.

''I'm the king of it all,'' the 40-year-old, unemployed Opa-locka man told The Miami Herald recently, when asked about his Medicare scams.

McCray, a ''professional patient'' with a 15-year criminal history of drug possession, is among thousands of con artists who have made South Florida the nation's capital of Medicare fraud. A six-month Miami Herald investigation has found that the corruption has spun out of control during the past decade with little effort by Medicare regulators to stop it here and in other major cities. This past week, during a policy forum to confront the crisis, federal lawmakers said Medicare fraud costs taxpayers nationwide at least $60 billion a year.

Read more here:  Rampant Fraud in South Florida



And in Brooklyn, New York

Federal agents raided health care facilities in nine states this morning, arresting dozens of suspects believed to be defrauding Medicare of tens of millions of dollars.

Federal authorities say this is one of the largest -- if not the largest -- take-down of Medicare fraud suspects ever conducted.

video platformvideo managementvideo solutionsvideo player

The raids began in morning in the pre-dawn hours. The targets: more than 100 doctors, nurses, therapists and healthcare company executives who have allegedly been stealing tax dollars to the tune of $200 million in recent months. Much of the fraud involved healthcare professionals billing the government for medical services never performed and medicine not provided.

Investigators say the Brooklyn scheme worked like this: Patients willing to go along with the scam were paid $40 per visit for three appointments per week, and were often diagnosed with vertigo or other ailments that would limit their mobility. Ambulettes provided by Medicare and Medicaid were transporting these patients back and forth for fraudulent appointments.

The clinic would then collect from Medicare or Medicaid for the ambulette rides, and the supposed services provided at the phony appointments. Taxpayers were billed millions for unnecessary treatment or treatment never provided.

The raids were conducted in Miami, Brooklyn, Tampa, Chicago, Baton Rouge, Houston, Dallas, and Los Angeles.


The Whistle Blower, and How to  Report Fraud

Here is another ‘tale of deceit’

A combination of events created this break in security.

Medicare received a series of paper claims for diabetic retinopathy laser photocoagulation from an ophthalmologist’s office. They were unusual, claiming a series of 8 treatments in a series for proliferative diabetic retinopathy.  While a series of PRP for PDR is not unusual 8 is highly unusual.  This medical practice used electronic billing exclusively, yet the claims were on paper forms. Each paper claim totaled 25,000 dollars and there was a series of claims totaling $ 875,000. The patient identification numbers and locations were not from the usual practice locations.

The paper claim had the correct MD name, Medicare Provider ID practice location ICD and CPT coding.

These events tripped off the Medicare fraud alert system. At the time the practice had been sold to another MD and a transition was in place. The original physician had relocated the to another state.

The claims were for procedures performed after the original physician had closed his medical practice.

The attorney general contacted the physician with many open-ended questions possibly suspecting the physician himself was the perpetrator of the fraud. It became readily apparent that this was not the case.

This physician's Medicare provider ID was compromised by a lack of security. It's important to remember that your insurance ID numbers are much like a credit card number, and are perhaps less secure since they do not require PIN numbers. The information is handled by many personnel in the billing office. In this particular situation there was also a change in office personnel.

It was determined that a previous biller was part of a scheme to defraud Medicare, either selling or giving the Medicare numbers to acquaintances who knew enough to use them to defraud the taxpayer of almost a million dollars.

A 'sting' operation went into operation allowing the thieves access to the money cashing their checks and tracing the money to a racetrack and a person attempting to cash the US Treasury check. Even more interesting was the checks were negotiated at a well known horse racing track in the greater LA metro area.

The perpetrators were confronted at the teller window by several FBI agents who inquired how they got the checks. The suspect turned around and said, “from that doctor over there'... (there was no “doctor over there”.

Fast forward about a month, when the MD received a call from an FBI agent who asked him to send him a copy of a photo of himself, a driver's license and a sample of his signature and writing sample. Even though completely innocent the physician realized how easily he could have been implicated.

As events turned out he was found to be an innocent victim of the scheme. He was required to appear before a grand jury where the guilty perpetrators were indicted, tried and sent to prison for felony fraud.

This was my personal story…it happened to me

This scenario while somewhat unusual is not unique. The moral of the story...treat your ID numbers as if they were credit cards, and if you make paper claims do not allow them to be known other than by your billing personnel.

Monday, February 20, 2012

Health Train at HIMSS 2012


Happy President’s Day !

Seems like a good time to visit Las Vegas for the latest on HIT.

Virtual HIMSS

HIMSS Mobile

HIMSS 2012 is the annual meeting of the minds where healthcare meets information technology, for better or sometimes worse.

It is one of those events where languages intermix. It is a cross-culture event where each side speaks, with the other side, sometimes with each party understanding the other party.

If you want detailed information in real time the best place to look is on twitter using the #himss12 to search or related #healthit.




2012 promises to be the year of the health mobile app. The maturation of the  Android OS  adding to the force of iOS allows many applications to be available in open source greatly expanding the ability of software developers in health care

2012 is also the year of the explosion of interest in  social media. The number of providers using social media rose exponentially during 2011.  HIMMS 2012 provides a number of events revolving around Social Media. #hsmc

The number of tweets/hour using #hmss12 about 1000. (February 20, 2012 at 12:00 noon.

Five things to Watch at HIMSS

Here are some of my favorite tweeps at himss12:!/PhilSalm!/larrylin!/HealthTechMatch!/HealthTECHlive!/iHealthBeat!/ahier!/Cascadia!/imrantech!/theEHRGuy!/Awarepoint

We’ll be watching on a daily basis and updates will be posted later in the day.

Technorati Tags: ,,,

Thursday, February 16, 2012

How United Healthcare Got it Right



United Health Care to offer Software in the Cloud (Ducknet)

UHC fooled us all with their end run around IT vendors, EMRs, HIEs and physicians.  While the peanut gallery and bleachers were watching Howdy Doody, HHS, and CMS real entrepreneurs ran the pigskin into the end zone.

Insurers are much more than sending a bill and getting reimbursed for services. That is just the front end of their IT systems. IT experts know the real stuff in IT is in the ‘back end’, the guts of the system buried in non friendly code, algorithms, application interfaces, backdoors for different insurance companies, etc.

Dana Blankenhorn writes in “Seeking Alpha” , an investment newsletter,

“When I took on the health IT beat for ZDNet five years ago, it was with the assumption that this industry would act as every other industry had acted. That is, mainstream tech vendors would gradually take out the specialists.

It hasn't worked out that way. Last year Microsoft (MSFT) got out in favor of GE (GE), which has been involved all along. Google (GOOG) simply bugged-out, a rare failure for the company. Siemens (SI), long an also-ran in most enterprise computing, has also been a big player in health IT thanks to its imaging unit.

But the big winner may turn out to be UnitedHealth (UNH), a healthcare vendor based in insurance.”

While other insurers signed vendor deals seeing IT as an obligation, UNH bought small vendors, seeing it as an opportunity.

Last year it rolled out a new brand, Optum, for its health services, and this week it rolled out what it calls the Optum Cloud, backed by a new data center.

The healthcare law, meanwhile, will bring UnitedHealth and its competitors, like WellPoint (WLP) and Aetna (AET) millions of new customers, but also a level playing field in many cases. It's an incentive for insurers to cut physician costs. That would translate into lower rates on health exchanges, thus more income.

The question becomes, can UNH break out of this high? Well, consider that now it only has to execute on a strategy that has government approval, with new services and new platforms coming on quickly. Signs point to yes. This administration has done UnitedHealth some big favors.

So, Meaningful use fueled interest in insurers to maximize their profits through health insurance exchanges, if those ever come to pass in some states. The money invested by the tax-payer will come around into insurers and Medicare (federal government)

Wednesday, February 15, 2012



How do Google + Social Media Impact upon Healthcare ?

How to sign up for Google + (even if you don’t have an EMR)

Besides +Peter McDermott there are many other YouTube video tutorials or you can contact me +Gary Levin and I will bring you into the fold.

Many of you already know I am a fanatical proponent of Google Hangouts and Google +

My enthusiasm is borne from the innovative IT and developers using this platforms interacting amongst each other in the google plus space. G+ allows me access to sources before they are released to the general public or those in the HIT space.

In order to obtain this level of efficiency I organized my Google + circle of friends into categories for healthcare, providers, mobile apps, Health 2.0 and others.

Once I had my circles organized it became productive and efficient to just open my 'stream' and information “streamed” out in ways that Facebook could not deliver. Twitter also has some of these attributes if you know how to use the hashtag to filter what you are interested in reading. It's main limitation is 140 characters which do not tell a story unless a hyperlink is eymbedded in the tweet.

My morning is spent reviewing my feeds, twitter, facebook and Google +. Although I am intrigued by the possibilities of using Google Hangouts it is restricted by it's lack of security and privacy required by HIPAA for healtcare.

Jonathon Schwartz CEO of Care-Zone has developed an application, Care-Zone which is a secure private system that providers, patients, and family can trust in communicating private information that should not be in the public domain.

Jonathon is interviewed here by Robert Scoble of Rackspace.

Care-Zone has both a desktop and a mobile app availble in iOS, or iPhone.

The website uses https// a secured internet protocol. Care-zone allows you to upload files, created a medication list, create a contact list, but has multiple short-comings that render it almost useless for caregivers.

1.It is little more than a private secure notepad

2.There is no ability to chat in real time, nor interface visually or audibly

3.Different care givers must log in after being invited to Care-Zone

4. The application has no ability to interface with either a PHR or EMR.


Could a Smartphone know you’re depressed before you do ?

Digital Therapy: Could a smartphone know you're depressed before you do?

A team of researchers at Harvard University are working on the logical next step: A smartphone app that can help treat mental health issues.

Mobilyze is a development tool that would work much like the Nike+Fuel Band.

The FuelBand has a few neat tricks to set it apart. Sure, it'll track your perambulations, but it also converts all of your physical activity into a kind of health currency called NikeFuel. It tracks steps walked and calories burned, but it also uses oxygen kinetics to take a more precise measurement of your exertion — and in true Nike fashion, it turns the result into a competitive sport.

The app uses a simple approach developed by an Australian psychologist. Users of the app are shown two different faces on their phone screen: One friendly and one hostile. The program merges the faces together, and then flashes a letter that you need to correctly identify.
It's believed that those with social anxiety tend to fixate on faces in the crowd who are hostile. The app helps break this fixation, re-training the brain and reducing anxiety. 

Recent studies show that using the new smartphone app helped reduce subjects' anxiety by 22 points on a questionnaire, as compared to an 8-point drop experienced by a group who didn't use the app.

But before you start trading in your doctor for an iPhone, it's important to note that not everyone believes that the app is special: A similar 22-point drop was experienced by a control group who looked at pairs of faces without the letter to distract them.
It could just be that the key to feeling better is simply the act of taking the initiative and doing something about your anxiety. According to one Chicago-area control group participant in the study, "I felt good about myself, that I was doing something for my issues, and a lot happened in those two months outside the study that could have helped."  (source)

Tuesday, February 14, 2012

Social Media for Veterans and Health Train Express

The VA has launched social media platforms for 152 VA Medical Centers

Gradually during the past ten years the Veteran’s Administration has taken on a new cadre of wounded and/or disabled Veterans. Today the Army and other branches do  not discharge soldiers until they have been through a vigorous appraisal while still on active duty.  This becomes an important part of their permanent medical record (via the VA AHLTA EMR if they ever have to apply for service  connected disability. At the time of discharge many are not yet aware that they may have PTSD (Post-traumatic Stress Disorder) or post-TBI  (Traumatic Brain Injury).

If you haven’t been to a VA Medical Center lately you would be surprised at the gradual metamorphosis the VA Centers have gone through since 1992 and the first Gulf war.

Many PCPs and other specialty providers may not be familiar with DOD process, nor VA Hospital paradigms for treating military personnel, nor the signs and/or symptoms of PTSD and TBI or how the two can be related to created a synergy that is challenging both to  provider and patient.


Introduction to Traumatic Brain Injury <VIDEO>

The Defense and Veteran’s Brain Injury website also offers a centralized information source.

For practitioners not directly affiliated Veteran’s Health Facilities the Department of The Army offers some practical information guides and brochures for both the veteran and his physician.

What is Traumatic Brain Injury ?  During the Iraqi and Afghanistan War the typical head injury changed from massive trauma and hemorrhagic injuries to chronic repetitive concussive (blast) injury from IEDs (Improvised Explosive Devices). In these cases the importance of a history of the injury, the distance from the blast(s) and the number of incidents to which the soldier sustained.

Important  Information For Every Soldier Regarding Traumatic Brain Injury (TBI)

Traumatic Brain Injury (TBI) Program Validation  AMEDD (Army Medical Department) maintains several programs which are linked to TBI and PTSD at Regional Centers. These are staffed with a multi-disciplinary team.

Here are some of the IEDs our troops faced:

Vehicle-Borne IEDs (VBIEDs)

The potential range for harm is impressive and exposes tens and possibly hundreds to injuries or death.

Other devices include:

Suicide Devices

Package Type IED

Many soldiers develop social anxiety disorders as part of the PTSD and post-Traumatic Brain Injury Syndrome.

What role does Social Media play in rehabilitation for these veterans? Would developing relationships on Facebook, twitter, and Google + hangouts benefit these returning soldiers.

There are already a number of advocacy groups for TBI and PTSD active on Facebook, which can easily be found by searching for TBI or PTSD.   For Twitter #tbi and #ptsd already exist.

The Road out of PTSD Hell  from Veterans Today

PTSD and TBI patients do not wear their scars externally. That person sitting opposite of you in the bus, in the restaurant may suffer each day for serving our country.

Monday, February 13, 2012

Will Accountable Care be the Final Straw for US Economy and Healthcare system?


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Few readers do not know about our present economic failures, and the prospect of inventing an unproven model to contain health costs could have the opposite intended effect, further increasing the %age of GDP devoted to US health care

Good afternoon readers. I tried to think of a short, catchy phrase for this subject, but failed miserably

For this post, however you will see with what I came up.

I have been pondering what a 'Project Manager' recruitment ad would read for establishing an Accountable Care Organization. I was about to construct my own plan and came upon this article from eHealthInitiative.

I found out very quickly what is involved.


Essential to the development of an ACO, small or large is Health Information Technology.

Key recommendations include:

  • a health IT infrastructure that is flexible to support the changing needs of an accountable care organizational model; (unknown at this time)

  • an infrastructure that supports the secure transfer, collection and storage of personal health data;

  • a patient-centered system to engage and educate patients and caregivers;

  • and a system that supports care coordination across the healthcare team and the patient.


"It may be difficult (read impossible) for accountable care organizations to accomplish all of their objectives without a strong technology base that facilitates care coordination and gives doctors the tools they need to provide quality and affordable care," said Jennifer Covich-Bordenick, eHealth Initiative's chief executive officer.

Accountable care is an issue of critical importance to physicians.................. With the right technology in place, these organizations have the potential to improve the health and well-being of their patient populations," said Michael S. Barr, MD, MBA, FACP, Senior Vice President, American College of Physicians.

The report was developed by a multi-stakeholder council which met over an eight month period, and involved the input of over 100 individuals and organizations across the healthcare industry. The council was co-chaired by Michael S. Barr, MD, MBA, FACP, Senior Vice President, American College of Physicians and Marcia Guida James, MS, MBA, CPC of Humana Inc.

The report can be downloaded on the eHealth Initiative Website at

Of some significance was that 50% of hospitals/groups are not interested in the ACO model.

eHealth Initiative 2011 Accountable Care Organizational Model Survey (ACOM)

The eHealth Initiative launched the Accountable Care Organizational Model Survey on October 7, 2011, and concluded the survey on November 29, 2011.

The survey of 20 regionally diverse groups revealed:

The majority of respondents were unsure or did not intend on applying for the Medicare Shared Savings Program or the CMS Innovation Center Pioneer ACO Model.

50% indicated that they did not intend on applying for the CMS MSSP program.

37.5% were unsure if their organizations intended on applying for the MSSP program.

12.5% stated that they intended on applying for the CMS MSSP program

ACOMS are utilizing a variety of payment models to achieve shared savings. Several organizations reported utilizing or planning to utilize a combination of models:

1. Twelve organizations reported utilizing or planning to utilize a FFS plus a shared savings payment model.

2. Eight organizations reported using an upside potential model.

3. Five models reported utilizing or plan to utilize a downside risk model.

4. Four organizations are utilizing or plan to utilize a bundled payment model.

Two organizations were utilizing a global risk model.

5. One model reported unsure.

I had not realized the ACO has the choice of a number of payment models and cost containment ranging from prepay HMO like contracts all the way to FFS with shared payment and cost containment measures

One of the key ingredients is the component of patient participation in health 2.0 which include:

Telehealth monitors.

Telephonic support.

Mobile technology.

Patient Portal.

Internet-based patient education programs.

Personal Health Comprehensive assessment tools to help providers determine the patient’s level of health literacy so that education can be tailored accordingly.

Online communications such as viewing a summarized patient record, enabling patient input, enrolling in health and wellness programs, linking to health information sites, managing permissions for record access.

I addressed these issues in my last article at HealthTrain Express “ Is The Patient Ready for Physician 2.0 ?

Whether it is a federally or provider-supported model, successful ACOMs will be judged on the basis of their ability to achieve progress in achieving the Triple Aim–improving the individual experience of care, improving the health of populations, and reducing the per- capita costs of care for populations

Key Attributes Needed for a Successful Health Information Technology Structure in the Accountable Care Organizational Model

Health information technology is essential to the success of the Accountable Care Organizational Model. The following list identifies key attributes needed for the development of a successful health IT infrastructure.

The health IT infrastructure must enable care coordination and collaboration.

The health IT infrastructure must enable and support the comprehensive and systematic collection, storage, management, and exchange of secure personal health information between and among healthcare providers, patients and other members of a patient’s healthcare team in the process of care delivery and care management.21

The health IT infrastructure must include revenue cycle management technology to successfully support the financial analyses associated with accepting, negotiating, and managing new and changing payment structures. The infrastructure should enable electronic acceptance, tracking and allocation of payments and should be able to handle the distribution of payments to individuals, practices, and other appropriate organizations within the ACOM based on performance associated with specific metrics of quality, cost and patient experience.22

Data exchanged by the health IT infrastructure should be maintained in a secure, HIPAA-compliant, online environment that allows role-based access to and sharing of data among and between stakeholders (including hospitals, physician practices, healthcare providers and payers).23

The health IT infrastructure should support the collection of information embedded in the workflow of healthcare delivery.

The health IT infrastructure should support the use of telehealth, remote patient monitoring, shared care plans, and other patient-centered enabling technologies between facilities, healthcare providers, and patients that securely exchange information.24

The information shared through the health IT infrastructure should be collected and stored in a manner that facilitates ongoing measurement of processes and outcomes related to quality, cost, and patient experiences at an individual and population level. The identified

The identified metrics will be important for the assessment of ACOMs.25

The health IT infrastructure should enable information to be transmitted, and accessible to all patients and healthcare providers authorized to view it.

The health IT infrastructure should integrate evidence-based clinical decision support system (CDSS) services into the workflow of care delivered by healthcare providers and their practices.26

The health IT infrastructure should support and facilitate shared decision-making and care plan development through the integration of information from all healthcare providers involved in the care of a patient. There should be convenient access to user-friendly personal health information organized to be meaningful for patients/caregivers and presented in a constant format across the organization.

The health IT infrastructure should support services for patients and caregivers to help them be informed, educated, and literate about personal health and medical conditions and to enable patient self-management of care.

The health IT infrastructure should offer support on-going self-care and wellness management functionalities including, but not limited to, coaching from healthcare providers and ongoing monitoring of progress to promote a dialogue between patients and healthcare providers.27

The health IT infrastructure should support the analysis of clinical, administrative, and financial data to support operations, improve care and better patient outcomes while optimizing the overall performance of the organization.28

To achieve the specific benefits health IT can bring to the ACOM; industry should focus on creating and implementing tools that address the key concepts. This report identifies three key concepts that the health IT infrastructure of the ACOM should support .

ehealthinitiative identified three main components that should be addressed by HIT

  1. Patient Safety

  2. At Risk Patient Populations

  3. Financial Accountability and Quality Management

The report can be downloaded on the eHealth Initiative Website at

Sunday, February 12, 2012

Participatory Medicine



Hacking Health - Part 1 from J Participatory Medicine on Vimeo.

Participatory medicine  is a  relatively new term coined by patient advocacy groups. It sounds good, so how do we define it?  Does it include knowing your medical history, maintaining a personal health record, being observant of maintaining one’s health with proper exercise, being knowledgeable about good nutrition, compliance with medication instructions, reading your medication side effects and/or contra-indications, knowing and telling your providers about allergies (on every visit), getting recommended vaccinations each year for flu, and pneumovax at the appropriate times?

Have you signed an advanced directive, and is it in your medical chart? When you enter a hospital  do you instruct registration and/or your nurse that you do or do not have an advanced directive? Do you bring all your medication bottles to the hospital? (Yes, even aspirin, Tylenol, decongestants, eye drops and sleeping medications. Do you tell providers about the supplements and vitamins you use, including herbals? Have you travelled recently? Many of our modern day powerful drugs are concentrates or synthetics developed from herbs. Do you practice yoga, meditation, reiki, acupuncture, massage therapy?  Have you travelled recently?

How far can you participate? You cannot hold a retractor or make your own incision for surgery, however you can be certain your nurse or other health care personnel know your name and to be certain that you are not getting someone else's medications or being taken for a procedure intended for someone else. You can tell personnel which side of your body is being operated upon.  Operating rooms now have a standard check-off list including a “time out” in which everyone participates.

There are a great number of items in which you can participate  and many that you cannot.  You can tell your nurse and/or doctor to wash their hands (they often just plain forget in the rush that has become part of medical care.

You can take a shower or bath prior to entering a hospital to reduce the possibility of transmitting an unknown pathogen on your skin, such as drug resistant bacteria like MRSA (methicillin resistant staphylococcus)  And if you are a known carrier of MRSA or someone in your family is a MRSA carrier, certain precautions will be taken by hospital staff (if you tell them)

Hacking Health - Part 2 from J Participatory Medicine on Vimeo.

None of these items create any increase in cost, all likely improve outcomes, decrease “never happen” events and do not increase the paperwork burden on the system.


And best of all it is a bipartisan decision on your part by a Committee of ONE , requiring no political action committees, nor 1200 page Federal Register entries.

Friday, February 10, 2012

Is The Patient Ready for Physician 2.0 ?

Gotta Webcam?

Health IT developers are producing medical applications for mobile users rapidly for both Android and iPhone, and soon for Window Phones.  Most of these are educational or for reference. There are some software applications for remote monitoring which are presently in the FDA approval process.

While pundits proclaim that patients clamor for direct “physician-patient” telemedicine”  Few if any real studies have been done to demonstrate this demand.

Until now there were few if any teleconference software that was affordable for medical practices and patients. In fact a teleconference room and/or facility costs in the range of five figures.  Skype has been available however it presents some limitations in regard to the number of participants unless users are subscribed to the paying service.

Health Train Express will be sponsoring a “Demonstration Project” on Physician-Patient Telemedicine.

I know, I know many will tell me I should not do this due to regulations and all, however progress is made by those willing to risk something in the name of REAL PROGRESS  instead of a bunch of committee meetings. Lett MDs be the arbiters of what works and doesn’t work. Once we demonstrate the need and demand for these services some innovator and entrepreneur will find a way to host medical teleconferences for an acceptable stipend.

The following caveats and disclaimers will be posted for each telemedicine conference to be held on Google + Hangouts.

[This is a “Demonstration Project in  telemedicine. The project will attempt to  determine what the demand is from patients for Primary Care and/or Specialty Care using Telemedicine  Because the Google + Hangouts are not encrypted we will only answer non specific general questions To be in compliance with HIPAA privacy and confidentiality laws DO NOT identify a problem or question with yourself. Please ask your questions in the third person (he, she, we, it)

We appreciate your interest in this telemedicine demonstration project. At the end of thirty (30) days the results will be published here in Health Train Express. The announcement will be posted on Twitter @glevin1  Facebook/gmlevin and Google +.

“During the Google + Telemedicine Hangout you will be asked if you agree to having your interview recorded.  If you decline it will not be recorded.  The recordings will be available to a closed panel of physicians and well known patient advocate and will not be released to the general public.  The review committee will comply with HIPAA regulations to protect your identity.  Your waiver of HIPAA regulations will only apply to the G+ interview.


Health Bloggers, #hcsm, #healthit #mapp # healthreform and #telemedicine readers, if you wish to join a telemedicine hangout contact me via email  at You will receive an invite for each conference.

I invite other physicians to join as part of this ‘ground breaking use of affordable and existing platforms. The platform will allow multiple consultations for an individual or group of patients.

Google has “mothballed” the Google Health personal health record for the time being. The statistical results of the study will be shared with Google in the interest of a professional encrypted platform in the future. 

Providers, I hope to see  many of you in this hangout.   Please use twitter, FB, and/or email to communicate with other physicians and providers regarding the demonstration project.

Wednesday, February 8, 2012

ACOs Are They a Social Media Experiment?

An email caught my attention this morning about the above flashing banner. It was published in “Accountable Care News”.  How Can Nurses Be Best Utilized in ACOs? by Mary Jean Schumann, DNP, MBA, RN, CPNP.

This question and many more like it are featured in this edition, including Positioning Specialty Services for Accountable Care by Philip Ronning

Volume 2, Issue 12 of Accountable Care News discusses key changes already proposed for the ACO rulings

Analysis of Key Changes from the
Proposed Rule
By Epstein Becker & Green, PC

The discussions are led by such luminaries as:

Molly Joel Coye, MD, MPH
Chief Innovation Officer, UCLA Health System
University of California, Los Angeles
Los Angeles, CA

Bruce Merlin Fried, Esq.
Partner, Health Care Group
Washington, DC

Paul B. Ginsburg, PhD
Center for Studying Health System Change
Washington, DC

Janet M. Marchibroda
Chair, Health Information Technology Initiative, Bipartisan Policy Center
Executive Director, Doctors Helping Doctors Transform Health Care
Washington, DC

Paul Katz
Intelligent Healthcare
Santa Monica, CA

The Program encourages the formation and operation of ACOs by promising
to share Medicare’s savings from the program with those ACOs that:  (1) meet
eligibility requirements; and (2) meet the quality performance and Medicare cost
savings targets described in the Final Rule. 

The most significant changes in the final ACO regulations are around the measures for establishing quality performa scoring.  The final regulations move from 65 proposed measures to 33 final measures.  They also limit the requirement
around advanced care coordination across the patient’s care continuum
.  Initially, this was a major concern of many organizations since creating an advanced integrated technical infrastructure was very expensive, and in some cases cost
prohibitive to organizations.

The experts argue the final regulations appear to create a nice balance between driving care coordination around patient quality outcomes to
reduce costs, and not overburdening organizations with significant new infrastructure investments.

The Devil is in the details, you can read it if you have the stamina to read all 189 pages of governmental control and loss of  marketplace freedoms.

If and when Obama Care is repealed the ACO Mandate should be included.

A wave of anti-ACO sentiment has been expressed by many hospitals and practice entities.  The already integrated health systems such as Mayo Clinic, Cleveland Clinic, Kaiser Permanente and others seem to be already eligible but for meeting criteria for savings.  The changes herein seem an attempt to assuage the anger and hostility of independent hospitals and medical groups toward HHS and more federal control.

All of this ‘organizational activity’ stimulates more social interaction and will drive discussions on social media sites such as Twitter, Facebook, and now, even Google plus.  Discussions will arise on Google Hangouts.



There are now several “Permanent Hangouts” indexed on Google plus. Click on “Permanent Hangouts” to see the directory, and add your own topic. The list can be found on Google plus using the G+extension.

Tuesday, February 7, 2012

Update on Health Information Exchange


Health Information Exchanges are the offspring of the failures of numerous RHIOs due to unsustainable business models. They are the same horse of a different color.

HIEs were empowered by the sequence of events beginning with George Bush appointing David Brailer MD to develop ONCHIT by executive order. It was then approved by Congress and funded as a regular agency. The passage of HITECH and ARRA (stimulus program) incentivized electronic medical records and Health Information Exchanges.

The February 1, 2012 meeting of the Health IT Policy Committee was provided with an update of the current status of the State HIE Program, as well as an update on the standards work and development of the NwHIN and Direct Project. This is a fascinating review and if you are interested in health information exchange, you should take the time to watch this. I believe it offers some hints towards the upcoming rule on NwHIN governance and the health information exchange requirements for Stage 2 meaningful use. Below is the presentation to the committee by Claudia Williams, ONC’s state HIE program director, and Dr. Doug Fridsma, director of ONC’s Office of Standards and Interoperability.

Slide share Presentation

Despite more than 8 years since the concept of RHIOs began and significant financial incentives as well as penalties for non compliance the adoption of HIE has been slow. HIEs develop slowly often because of financial uncertainty, lack of sustainable business models, and other factors.

These other factors include the realization by hospitals and providers that this added feature will increase cost and at the same time thus far has not demonstrated any return on the investment.  Perhaps this will change with time and the burden of paperwork, faxes and time required to obtain medical records decreases.

However, the record is not good. Measures of ROI thus far do not demonstrate decrease in costs. As the network increases there will be hardware maintenance, software developments and upgrade expense to add to the cost escalator.

CMS and HHS have funded EMR and HIE incentives with the agenda to recapture the taxpayer’s dime extracting information such as outcomes and treatment protocols in real life hoping it will decrease cost in the long run.  A large and risky bet, however it’s your money….However your practice, doctor is not too big to fail.

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Monday, February 6, 2012

It’s In Your DNA: Social Media


Take a look at the Info graphic below…. This is taking place in a single minute — every minute — of most everyday within the digital world….  

Still think it’s a passing fad?

Still think you do not need to establish some form of digital presence on the healthcare social media stage? 

—Think again —

Healthcare Social Media Digital Footprint By: Shanghai Web Designers

Howard J Luks M.D. points out the reasons why physicians should participate in the landscape of social media in his recent post via Summify.

Dr Luks message and articulation of the message is so well put that I repeat it here, and give him full credit for this information. It bears repeating in my blog(s).

I happen to agree with him. Issues surrounding health care and health reform have become much more public, open and transparent. Physicians must use the medium which is presently gaining momentum to replace printed and rapidly becoming obsolete magazines, newspapers and other forms of advertisement.

Let’s face it most studies and experience show the decline of ‘established newspapers, and journals. This is even more apparent in the under age 50 demographic.

Dr. Luks points out:

  • 50% of the world’s population is under 30. 
  • They do not communicate via e-mail or telephone. 
  • Generation Y and generation Z consider e-mail pass√©. 
  • The fastest growing segment on Facebook is women over 55 years of age.  
  • SMS, direct messaging, micro-blogging and digital media is fast becoming the chosen communication standard.
  • Drug/Medical related “Likes” on Facebook have skyrocketed.

Dr Luks goes on to elaborate:

50% of the mobile Internet traffic in most countries is for Facebook. One on five patients flock to Facebook for healthcare information.  Imagine what this means for a bad patient experience?  The world has gone digital —social media is here to stay.  1 billion people simply cannot be wrong. 85% of people log onto their Facebook account every single day.

Any news media presently in business  already has built or is building a social media presence. Twitter, Facebook and Google + seem to be in the lead of popularity and each has it’s own model which changes almost daily in an effort to capture the most users.

Recently I have been in several hangouts on Google + where people have asked for my medical opinion in the hangout. Each of them has expressed their willingness to “waive their privacy rights'” under current HIPAA laws.

Physicians are entrenched in patient privacy and confidentiality by their own training and ethics long before HIPAA was passed. Despite this restriction, many patients already waive privacy when they allow their story to be told  at grand rounds in presentations, for testimonials regarding treatments, in other media and for other purposes.   Does this carry forward for social media?

I would like to ask the readership their opinions and experience in this matter? How many of you have been asked this same question, and what have you advised? Would a verbal waiver be adequate or would you require it to be in writing? 


What most physicians recognize is that access to a physician (and almost any physician) is restricted by time and distance. Patient abhor our new systems of telephone trees and triage.  Numerous times potential patients express their desire to interact on social media or email with their physician even preferring to leave a ‘message’ via email, twitter or Google plus.

With the enormous increase in ‘Boomers’ our system is about to be stressed beyond it’s limits unless some creative steps are taken by universal acclaim. We cannot wait for governments to solve problems that physicians and patients are able to address together. The perfect storm of limiting reimbursements, and increasing benefits, and access threaten our health system.  The first step has already taken place by eliminating pre-existing conditions, and extending eligibility of children under the age of 25 under their parent’s policies.

Physicians should start thinking about setting aside fifteen to thirty minutes a day to devote to patient care via social media. Some are already doing this via secure email or built in secure messaging in their electronic medical record systems. However not all EMRs are created equal and most do not afford this feature.

Most patients no longer find a physician through the yellow pages..they search on Google. Google also indexes social media, and blogs. Their entrance to your practice (other than an insurance roster) is already via a search engine, be it BING, YAHOO, or GOOGLE, Twitter and Facebook. Patients can even invite you to a Google Plus Hangout. And these can be one on one.

Internet social media is only beginning and will be adapted in ways we cannot yet even imagine. It has already become a commonplace feature of broadcast television, anchor news, and international links between non major news sources for direct news bypassing conventional syndicated news sources such as CNN, FOX, ABC and NBC.  It may become a primary source for professional journal news releases.

The American Medical Association has published a statement regarding physicians’ use of Social Media

Stay tuned…different place, different station and at any time.

Friday, February 3, 2012

Are Physicians Becoming Extinct as Solo Practitioners?


While watching the  Presidential debates and listening to economists seeking the mysteries of how not to spend more than we ‘make’, it became to me that the health care industry suffers from the same malady that our economy faces.

Technology has accelerated and has outstripped our economic structure to adapt and transform. The same is true for health care. Much of it filters down to physician offices, medical staff structure, pharma, and hospitals.

Rapid obsolesence is least often recognized initially by the species that is about to disappear until it is moribund.  Early adjustments fail to correct the stresses, and finally it crumbles.  In the process the species dwindles and it’s population declines. Such seems to be the fate of primary care and solo practitioners. Studies of physicians who practice as solo practitioners reveal a dramatic shift to group pracice and to being employed by a group practice or hospital  as opposed to being employers. What and when wil the “extinction event” occur?

American physicians are hell bent to maintain autonomy and some semblance of rule and control of their workspace.  Opinions on this are wrought with emotion. So we as physicians are at the point of “I am mad as hell, and I am not going to take it anymore”. In many ways this self-serving emotion flies in the face of mounting evidence that it takes a ‘team” to treat illness and even more so with serious illness.

Much of our economy derives success on productivity. In medicine we have formerly measured productivity with volume of patients seen and/or income.

We now see productivity in health care beginning to be measured with outcome studies,, the rate of readmission to the hospital, the incidence of acute heart disease,declines in morbidity, life span, and reduction of costs, and improved efficiency delivering health care. Much of this involves wellness and modifying factors that decrease immunity, decreasing stress, avoidance of improper nutrition and encouraging physical fitness..

We need to start on all of this early in life…in early childhood.

Wednesday, February 1, 2012

Fast Track for Health Train Express


The Food and Drug Administration today approved a new drug for the treatment of Cystic Fibrosis three months earlier than expected..

This comes as exciting news for families with anyone with this dreaded illness.

Cystic fibrosis

Cystic fibrosis is a disease caused by a gene mutation which causes a defect in chloride transport across the cell membrane in pulmonary and pancreatic cells. It causes severe malnutrition as well as pulmonary insufficiency leading to markedly premature death. Without treatment the average survival rate is 8-13 years.

This blinded placebo study of 213 patients revealed a marked improvement in lung function and reduction of disabling symptoms

The first version of this treatment was released for immediate use. It is meant for persons with the G551D CFTR mutation. Prior  cystic fibrosis treatments included drugs that alter effects of the defective CFTR protein which produce thin mucous, antibiotics to fight infection as well as enzyme replacement  for severe pancreatic enzyme deficiencies.


The drug known as Kalydeco and developed by Vertex Pharmaceuticals, counters the effect of one specific mutation in the gene that accounts for 4 percent — or about 1,200 — cystic fibrosis cases in the United States.The drug is approved for patients age 6 and older with the G551D mutation.

Although Kalydeco treats a very small subset of CF patients,The Cystic Fibrosis Foundation said there is an ongoing phase 2 trial for people with the more common CFTR gene mutation, using Kalydeco alongside a second experimental drug, VX-809. Findings from the first part of this trial have been encouraging, with the second part still underway.

Kalydeco, known generically as ivacaftor and during its development as VX-770, will cost $294,000 a year, a price roughly in line with those of some other drugs for extremely rare diseases. Vertex said it would have various programs to help patients pay for the drugs or obtain them free.

About 30,000 Americans have cystic fibrosis, which is caused by mutations in a gene called CFTR that is responsible for transport of chloride ions across cell membranes. People with the disease tend to have thick mucus in the lungs, which leads to infections and lung damage. Their average life span is 37 years.

Venture philanthropy played a large role in the drug study.  The Cystic Fibrosis Foundation invested  $75 million dollars from it’s charitable treasuries into Vertex Pharmaceuticals after assessing early animal studies which predicted  the potential for the new drug. The CF foundation raises about $ 40 million dollars each year with it’s annual “Great Strides for Cystic Fibrosis” and the “65 Roses’  fundraisers each year. The events are held annually in many cities by the local chapters of the CFF.

The gene controlling CFTR was discovered 25 years ago, and it has taken that long for translational research to produce a successful treatment.  This treatment is not a genetic treatment (which was attempted, and failed) but a direct repair/replacement for the defective chloride transferring protein in cell membranes.

The story of how the term “65 Roses” came about is one unto itself,

Mary G. Weiss became a volunteer for the Cystic Fibrosis Foundation in 1965 after learning that her three little boys had CF. Her duty was to call every civic club, social and service organization seeking financial support for CF research. Mary's 4-year-old son, Richard, listened closely to his mother as she made each call. After several calls, Richard came into the room and told his Mom, "I know what you are working for." Mary was dumbstruck because Richard did not know what she was doing, nor did he know that he had cystic fibrosis. With some trepidation, Mary asked, "What am I working for, Richard?" He answered, "You are working for 65 Roses." Mary was speechless.

Since 1965, the term "65 Roses" has been used by children of all ages to describe their disease. But, making it easier to say does not make CF any easier to live with. The "65 Roses" story has captured the hearts and emotions of all who have heard it. The rose, appropriately the ancient symbol of love, has become a symbol of the Cystic Fibrosis Foundation.

65 Roses® is a registered trademark of the Cystic Fibrosis Foundation.

In 1969 when I was a pediatric intern at Henry Ford Hospital I cared for three children ages 7-10 years old with severe pulmonary insufficiency and malnutrition. None weighed more than 60 pounds. None lived another six months.

Fast forward 20 years.

In 1991 we were served  with the diagnosis of cystic fibrosis in my second son. I promptly passed out. 

He is now age 23, the beneficiary of early effective treatment  (starting in 1994) with Pulmozyme (DNAse which thinned his thickened pulmonary mucus, inhaled Tobramycin to suppress Pseudomonas and to treat MRSA. The CF gene was identified early in his life. He has been in several FDA clinical trials for new drugs that will soon be released.

The financial challenge to families with this disease is enormous. His monthly prophylactic treatments average $3500-5000/ month.(when he is well) About every 12-18 months he receives a three week course of two or three antibiotics at home via a percutaneous intravenous line. The treatment is started at the CF center and then continues as an outpatient at home.