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Friday, March 29, 2013

Ben Carson M.D.


Product Details


Medicine’s new rock star is a quiet but outspoken Pediatric Neurosurgeon, the Head of the Pediatric Neurosurgery Department at John Hopkins University School of Medicine in Baltimore, Maryland. He received the Presidential Medal of Freedom in June 2008 the highest civilian award in the United States. It recognizes those individuals who have made "an especially meritorious contribution to the security or national interests of the United States, world peace, cultural or other significant public or private endeavors

PresMedalFreedom.jpg Presidential Medal of Freedom

Carson’s ratings have skyrocketed since his keynote speech at the National Press Club’s annual event.  Sitting at the dais with Barak Obama at this right, Carson set a high benchmark for values and morality.  Obama who considers himself a benchmark for social justice seemed dazed and unable to respond.

Image of Ben Carson


America !  Ben Carson has your attention, so listen  carefully. The attacks on Carson have begun, with PC statements about ‘gays’ which Carson apologized about.

The best way to divert attention from the message and/or messenger is to introduce chaos with a totally irrelevant complaint. Carson’s message is one every American, politician and decision maker needs to keep in his mind (and heart) while they go about their business.

Although famous in a relatively small subspecialty of medicine, Carson was not well known to the general public.  His academic and surgical skills have taught many neurosurgeons to accomplish what once seemed impossible.1

Thus far he has been accused of being disrespectful to the leader of the free world, using derogatory remarks about gays.  Soon there will be accusations of infidelity, pedophilia (he does operate on children).  Of course none of which are true.

Did I tell you that he was born into a poor black family ?  Images of his hard working mother standing watch over him and his brother insisting they read each night.  Ben’s life could have gone in the opposite direction. 

Carson is at the age of retirement from his medical practice, however we will be hearing a lot more from him about social issues.  I recommend everyone read his biography, and the other books he has written on his Amazon Page .

Carson has the ability to carve out the essential forces at work in society which have become over-riding and interfering with proper decision making which threaten the fabric of American ideals.

We now live in a ‘comfort zone’ where decisions are based upon the profit, either in money or influence, rather than the true value of a decision.

Ben Carson MD is one of the true voices of American Medicine, he deserves all our support regardless of your mode of practice, solo, group, integrated health system.

His essential message to  us all is to maintain our integrity of beliefs and insist they be met by our health system.

His not so shocking message is not that surprising to any of us at all. The shocker is that he makes it so plain that maybe even a President could understand it.  President Obama has made no comment, thus far.

The Republicans seem anxious to appropriate him for their own selfish purpose.  I advise Ben to stay independent.



Tuesday, March 26, 2013

The ‘INBOX"’ for the Health Train Express


My morning routine opens with GMAIL, followed by my Google notifications, often they duplicate each other since I have my preferences set to notify me via email of notifications. (I know it seems redundant, but it helps somewhat to organize priority notifications.

Next is reviewing Google Reader (in the process of syncing with Feedly and Old Reader. as well as Newsblur).   At first the news about Google Reader going to the happy hunting ground was devastating, however we have adjusted accordingly with some unexpected positive consequences for all.


At this point I am reading my inmail subscriptions to several internet medical newsletters, including California Healthline and iHealthbeat, both publications of the California Health Care Foundation. (a non-profit organization) There is some redundancy in their reporting but not always. There are also a variety of subscriptions, such as the Medicare News Report, Inside Health Policy and a number of health care related social media sites filtered by hashtags on twitter. The only thing I will miss in Google Reader is it’s tight integration with Google + and Gmail overall.

My next stop is on my #hcsm twitter feed (I use tweetdeck as well to follow the following # tags,  #hitsm #aca #mhealth. Each week I review meetings that are being held. I can usually find their #tag at Symplur (the Hashtag Directory) I belong to several groups on Linkedin in the HIT and healthcare group  as well.

There’s more, however I have drifted away from health related issues..

Monday, March 25, 2013

Health Train Special Edition


Thanks to  the “Galen Institute”  Health Train Express is privy to this information, which falls under the FOIA. (Freedom of Information Act)

In order to qualify and seek eligibility information regarding how to become insured under the terms of the Affordable Care Act (Obamacare), you will be able to go online and file.


Health Benefit Exchange. HBE EZ form

Health Benefit Exchange.  HBE Long form


The Red Tape Tower: The pièce de résistance at the moment is the Red Tape Tower (#RedTapeTower) showing all 20,000 pages of the ObamaCare regulations that had been issued as of March 8.  The tower was a star at CPAC, and Senate Minority Leader Mitch McConnell received hoots and applause when it was rolled out for so graphically visualizing the incredible burden this law is placing on the health sector and economy.  National Review tells the story and has the photo.

The Patient Protection and Affordability Act has grown from an adorable 2,700-page binder full of rules and kickbacks into a towering 7-foot-3-inch, 300-pound behemoth totaling more than 20,000 pages of byzantine mandates and regulations.

The “red-tape tower” has been making its way around Washington, D.C

The NPR article and photos are making the rounds on social media,  including twitter #redtapetower and Facebook

Promises we cannot keep !

For those who like charts and pictures

Our New Health Care System

My thanks to Grace-Marie-Turner and the Galen Institute


Don’t Leave Home Without Me



Op-ed:   Gary M. Levin M.D.

The Riddle

The Health Train Express is leaving the station and perhaps the tracks with many physicians not onboard. This despite health providers never ending pleas to delay the departure.

Many have not boarded because the train really does not know where it is going, nor what the actual fare will be, nor it’s destination.  (Sound familiar?) It should, because that is what the Accountable Care Act offers.  Despite the goal of taking everyone to some destination, and providing ‘free tickets or deeply discounted fares, there is much reluctance to believe or trust the conductors or the barons of the train industry.

For some, the ACA is good news and virtually guarrantees employment for nurse practitioners, physician assistants, and many physician extenders.

There is a serious disconnect between providers, hospitals and payers, not just in reimbursement needs, but in overall organizational liason.  Every hospital and provider seems to be on it’s own track, and the patient comes in dead last. Hence the badly needed patient-centric approach.

Why not ?  It’s complicated.

As far as electronic records are concerned it is far more complex than the ubiquitous ATM (long used as a comparison between banking and medicine).  The advocates were wrong.

Saturday, March 23, 2013

FDA and Mobile Health Apps


The Sprawling leviathon Food and Drug Administration Complex is struggling to keep up with drug review, and is now facing additional challenge of mobile health regulations in the face of  [Governmental Sequestration.]    [Washington Post Opinions]

Sprawling leviathon Food and Drug Administration Complex struggling to keep up with drug review, now facing additional challenge of mobile health regulations in the face of Governmental Sequestration.

Three days of congressional hearing with the FDA concluded with discussions about the FDA’s role in monitoring and producing guidelines for mhealtlh applications. There were no specific guidelines, nor binding regulations forthcoming at this time.


iHealthbeat reported this yesterday, along with other topics.


Flawed HER Designs

Lag of Long Term Facilities in HER adoption


HIMSS Hot Topics:



HIMSS13: Mostashari Says Data & Incentives Matter

HIMSS13: Federal Officials Stress Commitment to Health IT

HIMSS13: Sequester Will Affect Medicare EHR Pay, ONC Budget

11 Experts on Health IT Progress, Frustrations and Hopes for 2013

With 2012 now behind us, we asked 11 leaders in the health IT field to reflect on the progress and missed opportunities of the past year, as well as their hopes for health IT in 2013.

The meeting at HIMSS 2013 produced an intense focused forum for discussions about the progress of digitizing health information.  Most leaders in HIT were present, and many vendors were present on the meeting floor.

Unable to attend in person Digital Health Space monitored several live twitter streams, and also video live streams.  Microsoft’s health division and Dell Systems sponsored an evening meeting for a roundtable discussion of some high points of the meeting.

Hashtags from Dell's HIMSS Meeting:

You can  follow the tweets via the hashtag #DoMoreHIT or the participating tweeps in the conversation: @drandylitt, @ahier, @egpierro, @techguy, @lsaldanamd, @cthielst,@2healthguru, @jloveloc, @norabelcher, @boltyboy, @shahidnshah and @healthcarewen.

Implementation of HIT is turning out to be a “Big Bang”, an issue which challenges our ability to get our hands around it.

Presenters indicated how costly the effort has become, estimating that about $ 25 billion USD is the annual HIT budget at present, just to maintain current systems. At the same time most indicated that this offered employment security for many people at that meeting.  In the midst of the economic crisis it is not yet apparent what or if any of the HIT federal incentives will suffer.  Health now provides employment for a large segment of the U.S. Economy and reductions in health expenditures may be felt in the unemployment rates.

The topic of ‘BIG DATA” emerged as to how it would enter into the equation. Attendees at the Dell sponsored forum were sure Big Data would play a major role. The theory is that analysis of this forthcoming tool will improve outcomes and reduce costs.  The Kaiser model seems to bear that out, but it will take immense effort to convert the rest of American Health Care.  Other countries in Asia, and Europe are significantly ahead of the United States.

Big Data was vaguely defined. It was unclear if analytic systems were really in place to understand it, although it was mentioned that some large integrated systems such as Kaiser were already utilizing “Big Data”.  Most participants agreed that most hospitals and providers were not at all prepared for “Big Data”, that a large challenge is to educate 800.000 providers, and several thousand hospitals.

What organizations can encompass this ? State, county, Public Health, Health Information Exchanges.  The ‘baby” is still in the womb….what will emerge is still unknown.

Finally the topic of personalized medicine was discussed, in connection with advances in genomics. Exponential decreases in the cost of analyzing one genome have occurred due to immense increases in computer power.   We will be discussing personalized medicine and genomic in one of our next blog posts.

At times there are more questions than answers, a good sign of interest in solving our health challenges. 

The choices for organizational hierarchy changes, rapidly expand in number and perhaps we need an IBM Watson to analyze our organizational structures of health care to prepare a diagnosis and then a treatment plan  for our health system ills. How about several second opinions before the operation?

Thursday, March 21, 2013

First Amendment Extends to Health


2004 Democratic Convention Freedom of Speech Zone.

File:First amendment zone2.jpg

We physician bloggers and social media gurus have a tremendous responsibility as we take risks reaching out to our patients, legislators, insurers, and other pundits when we express our honest opinions.

Ben Brown wrote in his blog a well written and graphic  appraisal about the ‘Deceptive Income of Physicians”.  There are over 800 comments, 95% in agreement, 3% opposed and 2% saying it’s true but we should not ‘complain’ because we are “so lucky” and fortunate.  I disagree.

In fact I posted  a reply,  “Physician Privilege”  which drew some critical comments from some very highly respected “authorities” on health systems.  The reply to me was at the same time,  right, and wrong. Wrong because they felt I diminished my stature by my anger and frustration at what has happened to our privileged and beloved profession., and the fact that the wheels are coming off the bus, along with the rest of our society. We all have a right to express our thoughts, good, bad or indifferent. Disagreements can occur among agreeable people. Legally it’s protected by the First Amendment (Freedom of speech).

There is passion on both sides of this ‘fence’. The fence established a boundary, both protecting  each from the other, and a barrier to understanding and agreements. Perhaps this is human nature.


Tuesday, March 19, 2013

Heavy Weight in the Mobile Health Zone


Several years ago Google Health was developing  a personal health record. It failed to attract much interest  due to consumer apathy and  lack of interoperability with electronic medical records and an inability to download information from the clinic EMR.

About the same time, Microsoft developed Microsoft Health Vault. It has languished in a torpor and now that Microsoft has entered the mhealth zone, with ‘Surface”, “Windows Phone” and Windows 8 Microsoft.  These are all based upon Windows 8 GUI, which features large icons, a simple main menu and touch screen functionality.

The early edition of Microsoft Health Vault was tied to the desktop or laptop until very recently.

Microsoft has correctly read the marketplace, albeit very late. They finally came to the table with Windows 8RT, and Windows 8 Professional as well as a well designed tablet, Surface.

Microsoft also recognized the  exit from desktop and fixed locations. The transition to mobile should empower and engage patients to  get their healthcare from where they are, at work, in the car, or even outside.

Health Vault in the past several years has attracted many to the platform, laboratories, pharmacies, health and wellness, remote monitoring and more.

What can you do with HealthVault?

Microsoft HealthVault  is a free web-based platform that enables patients to collect, store, and share their health information, without charge.

Take the Tour

Prepare for an emergency

Use HealthVault to make your most important health info available

Browse the App Directory

Browse the Device Directory

Pulmonary Flo-meter        Pulse Oximeter


 Discover apps & devices

There are now several hundred mobile and remote sensing devices which interface directly with Microsoft’s Health Vault.  There is easy access to information and the ability to purchase apps and devices. All of this is designed to be patient-centric and user friendly, HIPAA compliant and requires authentication for secure transmission of data.

Microsoft Health Vault SDK  provides  a software developers toolkit for developing applications.

HealthVault-connected apps are websites, computer software, and mobile apps that can help you get more out of—and put more into—HealthVault.
You can choose apps to help you stay motivated, analyze trends, and receive education and recommendations to keep you at your best. And it is designed for the rapidly growing niche of mobile applications, available almost anywhere.

It is a welcome addition to the PHR market.

The most interesting part is the list of devices for remote monitoring and health and wellness .

Microsoft even has social media engagement for many of their products.

Twitter            Facebook       


Empowering Patients


Health Vault in Action

If you’re like most people you just don’t want to sit there and enter your health records into a personal health records..Well, now there is a cure for that as well. Unival PHR  is a service for obtaining your records from wherever they may be.

yourPHR, part of the yourHealth suite of services, offers three solutions for getting your medical information into HealthVault. Choose one or all of the following:

  • Full data conversion of your medical records by a trained, experienced nurse abstractor
  • Direct import of organized, scanned documents
  • An online interface to complete specific aspects of your personal health record such as demographics, insurance information, etc.

Sunday, March 17, 2013

The Problem with ACO’s

The most efficient means of using ACOs is to employ physicians by a hospital.  Kaiser get’s around this because Southern California Permanente is a foundation which employs the doctors and Kaiser Hospital contracts with that medical group.  That is because hospitals were previously forbidden to hire physicians.  Time and trends have altered that formula, however legally hospitals are banned from controlling physicians due to a conflict of interest.  I believe it should still be the same, and it may be that in certain regions ACOs may fall under anti-trust regulation.

Many physicians have ‘rolled over’ and succumbed to threat of insolvency, brutal administrative loads, the threat of malpractice, long hours and irregular call schedule.

Social media is playing a larger role with open communications which are transparent and reveal how dissatisfied physicians have become with the system, the dysfunctional way the accountable care act is attempting to correct increased costs, and improve outcomes. The addition of electronic records, while having some merits has added to expense, decreased efficiency,  and has converted a highly skilled physician who usually generates at least $ 200.00/ hour in gross revenue (before overhead and tax burden) into a clerk (hire for 12.00/hour),  The wise thing to do is pay a clerk $96.00 dollars/day + adjunctive costs such as health insurance, overhead for workman’s compensation, liability, vacation time, etc.  It is often said that an employees salary is double by ancillary cost.  Using that formula that clerk would cost about $180.00 per diem.  However each time you hire an additional employee it adds to the complexity of the human equation, absenteeism and more.

Add to all the above the mandate for outcomes, reduced readmissions, and demand for analytic data pushes the balance toward ACOs

Physician Employment Statistics


EHRs Lose Money for 1/4th of Physicians, Study Says


Medscape, an online service for physicians offers continuing medical education and presents the results of many studies in medicine.

Medscape reported the following from  a study published online today in the journal Health Affairs.

Attribution is given to the authors who produced the information in this report.

Lead author Julia Adler-Milstein, PhD, an assistant professor at the University of Michigan, and coauthors projected the average physician to lose $43,743 over 5 years and only 27% of practices to achieve a positive return on investment (ROI). That percentage of in-the-black practices would increase to 41% if they received $44,000 in meaningful-use incentive payments over 5 years.

The good news in the otherwise discouraging report is that practices achieving a positive ROI did so in part by using their EHRs to significantly boost their revenue.

Dr. Adler-Milstein and coauthors based their findings on a survey of 49 practices in a large EHR pilot program called the Massachusetts eHealth Collaborative (MEC), organized by the American College of Physicians and the Massachusetts Medical Society. MEC paid for the EHRs and the consultants who helped the practices implement the technology from March 2006 through December 2007.

The study did reveal differences in the return on investment between very small practices and those with six or more providers using EMR.

The elimination of paper records coupled with change management in the practice combined to offset some of the investment in EMR.

The figures varied substantially as to ROI and the time to running in the black. Although the average physician was expected to lose $43,743 over 5 years, the damage was not as bad for physicians in primary care, who lost $29,349 compared with $50,722 for specialists. Unlike smaller practices, groups with 6 or more physicians posted a positive though meager ROI — an average of $2205.

Julia Adler-Milstein

Dr. Adler-Milstein and coauthors write that an investment in an EHR system may not pay off for practices who fail "to make the operational changes required to realize benefits."

Even more significantly, the 13 practices with positive ROIs averaged $114,613 in additional revenue attributable to their new EHR systems compared with only $9204 for the 36 practices with negative ROIs. Five of the practices with positive ROIs reported that their EHRs allowed them to see more patients per day. And 9 practices boosted revenue through improved billing. Their EHR systems produced more error-free claims, resulting in fewer rejections. Plus, the technology allowed physicians to more accurately code their work, which solved the problem of undercoding and led to higher reimbursement.

However, the study authors note that revenue gains based on more accurate coding highlight "the potential misalignment between optimal provider use of EHRs and the savings that policymakers hope will result from greater EHR adoption, underscoring the recent concern about the potential for EHRs to drive up healthcare costs."

This occurrence would fly in the face of attempts to decrease cost based upon procedural coding, not outcomes, nor quality of care.

The authors write that more small practices might recoup their investment on EHRs and then some if the federal government increases the size of meaningful-use incentive payments. However, a "more compelling approach" would be to pursue policies that reduce the cost of EHR adoption and increase its benefits. Encouraging small groups to join larger ones could shrink adoption costs through economies of scale. And more practices could learn how to reorganize their operations to exploit EHR technology if the government increased funding for so-called regional extension centers that help with implementation.  This however would introduce complexity into management of a practice. It also involves merging differing corporate cultures, which can doom mergers. Increasing practice size may financially seem desirable, negative offsets can cancel out other gains.

Coauthor David Bates, MD, MPH, reported serving on 2 advisory groups for the federal Office of the National Coordinator for Health Information Technology and having financial relationships with a number of medical device and information technology firms. The other coauthors have disclosed no relevant financial relationships.

Health Aff. 2013;32:562-570. Abstract


Cautionary Tales from (The Crypt) HIT Consultants


At times when I hear the words EMR, ONCHIT, and Meaningful use and incentive payments,  it brings me back to the television program

Digital Health Space continues to monitor the progress of EMR implementation, HIX development and Meaningful Use Incentives.

Should you apply for EMR incentives at this time? (or ever).  CMS continues to promote EMR and incentive programs, but are they honest or just driving a data collection system that has not yet proven it’s worth.  They report a continual growth in physicians who have adopted some form of  EMR which is compliant with meaningful use criteria.

If you are confident that EMR is a good thing, promotes better patient care and is in the best interest of the patient, and if you are willing to take a one in four chance that your EMR will not have an ROI in four years. Those are the latest statistics from Sunday’ Health Affairs.  Factor another risk factor into your equation. The likelihood your EMR vendor will become insolvent, be acquired or merged with a stronger financial partner.  Or what about your software being purchased and then deprecated, losing support.

In addition to those numbers, loss of efficiency, possible loss of staff from workflow frustration and disruptive technology may cancel or even negate use of EMR.

Incentivization only covers the cost of immediate capital outlay, not ongoing maintenance which has been shown to cost as much as the initial system acquisition.

Julia Adler-Milstein of the University of Michigan and colleagues reviewed survey data from forty-nine community practices in a large Massachusetts EHR pilot and projected that only 27 percent of practices would achieve a positive return on investment in five years; an additional 14 percent would be in the black assuming they received the $44,000 federal meaningful-use incentive, the researchers write in the March issue of Health Affairs. The biggest determinant of whether practices achieved a positive return was whether they used EHRs to increase revenue by seeing more patients or through improved billing. The incentives had a larger impact on practices with more than six physicians and those that provided primary care, compared to smaller and specialty practices.

Truth and lies

And this very feature flies in the face of a paradigm shift for payments to eliminate procedural based fees.

Most current EMRs are not designed to base billings on  outcome studies, or increased efficiency. Each philosophy is counter to the other.   At this time there is little  connection (if any) between hospital billing and physician outpatient billing.

The unstated purpose and result of ACO formation is to employ physicians to be paid by a larger entity such as a hospital or a healthplan. (which in many cases is already in place)  There are fewer plans now based truly on indemnification.

Health Train Express and Digital Health Space’s mission is to aggregate, focus and opine on the course of health reform, giving the healthcare community a knowledge base to bring factual information to physicians, hospitals, health consultants and legislators.

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears each month in print, with additional Web First papers published weekly at

Tuesday, March 12, 2013

Health Reform Office Hours


Those who are implementing  the accountable care act are not the same as those who wrote the law.

Scott Gotllieb who is a practicing physician and also writes for the Wall Street Journal points out that many of the centrists who wrote and refined the accountable care act have left the White House Office of Health Reform.

President Obama has at the controls as his right hand woman Jeanne Lambrew, not the Secretary of Health and Human Services,  Kathleen Sebelius.

Who's In Charge Of Implementing Obamacare And Why It Matters

It’s a relevant question now that the White House is finally releasing the pivotal regulations that outline the shape of the new insurance scheme.

Scott Gotllieb  wrote more almost three years ago, in the New York Post, that many of the Obama Administration’s economic centrists were leaving the White House. Left behind were some of the most progressive staffers. They would be the ones implementing the law.

That transition now seems to be complete. The few remaining centrists thinkers inside the White House, mostly scattered across the National Economic Council and Treasury, are gone – or largely marginalized when it comes to issues around implementation. The people drafting and reviewing the regulations are mostly centered in the White House and its Domestic Policy Council — and they mostly work for Jeanne Lambrew.

Normally, the Office of Management and Budget and the National Economic Council would be heavily engaged on the issuance of regulations tied to a major law like Obamacare. Not the Obama White House. The economists still play on the fiscal issues related to Medicare and Medicaid. But when it comes to Obamacare implementation, they are not calling the shots. The power is centered on Lambrew.  Lambrew is a highly competent policymaker and power player with deep experience in healthcare. A former Senior Fellow at the Center for American Progress, she is also unabashedly liberal – often serving as the architect of her party’s most progressive ideas on healthcare reform. 

After laws get passed, the principals in an administration move on (especially in a second term). The implementation work is left to the policy wonks. Those wonks tend to be a party’s true believers, representing the ideological wings of their political parties. Lambrew is deeply progressive, and will hew in that direction at the many regulatory decision points that the law leaves murky.

The only difference in this White House is how little influence the economists seem to have. And how successful Lambrew has been at consolidating her power.  It seems all the moderates and centrists were dejected as to how it turned out and abandoned ship, not to be labelled with the coming failures of Obamacare.

A major stumbling block for passing a workable law was the defeat of Senator Daschles’ appointment as head of HHS in lieu of Ms. Sebelius. Daschle’s defeat was another political twist in the hanging of health care in the United States.

CMS Demonstration Project Proposed


Medical Access For America

BREAKING NEWS: Congress to make MedAccess (Community MedPac) a Pilot Program!

Medical Access CMS Pilot Program

BREAKING NEWS............................
The U.S. Congress has sent a letter to the Centers for Medicare and Medicaid Services to make MedAccess (parent organization of Community MedPac) to become a pilot program under both Medicare and Medicaid. A letter from one of the many members of Congress who directly supports us can be read here:  Letter from Congresman Alan Grayson

Want to be apart of our pilot program, send an e-mail to for more information.

Monday, March 11, 2013

“Being the Best We Can Be”: Medical Students’ Reflections on Physician Responsibility in the Social Media Era

I considered another title for this blog edition, “Kindergarten for MDs in Social Media”

Many medical schools have incorporated the use of social media into a medical ethics course. By the time students have entered clinical practice they are comfortable using social media in their daily tasks.

More senior physicians are in a quandary with social media and exhibit discomfiture with social media, not certain where to categorize it.

You can use social media in a variety of settings, but not for discussion of patient events which are not deidentified.

In my experience the best way to take on social media is to watch, listen, and learn.


The University of Southern California (Keck School of Medicine) took the easy going environment of social media and did an academic study with a peer reviewed evaluation of social media and it’s characteristics along with an analysis of it’s participants.

Lie, Désirée MD, MSED; Trial, Janet EdD; Schaff, Pamela MD; Wallace, Robert MD, MBA; Elliott, Donna MD, EdD
They preface their article with the following

“There is scarce literature on a curriculum to address this emerging need in professionalism education. Importantly, little is known about whether and how students respond to such curriculum and how effective it may be at changing personal online behaviors. We therefore conducted a mixed-method study with first-year medical students to examine whether a brief, required, two-hour intervention embedded within a professionalism course was associated with a change in students’ attitudes and use of online social media. We hypothesized that the intervention would be associated with increased awareness and action among students to change their online presence to reflect their new professional roles.”

During the Professionalism and the Practice of Medicine (PPM) course, we introduced this new curriculum. PPM is a 200-hour required course that spans the first two years of medical school.18Two faculty mentors teach the course weekly in groups of 24 to 30 students using a standardized, case-based curriculum that includes professionalism, bioethics, narrative medicine, cultural competence, integrative medicine, community health, health policy, and the business of medicine. In 2011, we added a two-hour session that covered the 2011 AMA social media use guidelines.1

In an era when the public and patients can easily access physicians’ personal and professional information online,27–29 and physicians may be (rightly or wrongly) judged by their online social media presence,24–29 educating medical students early about the implications of their online presence will be integral to professionalism teaching. Our study suggests that students already have a strong Web presence and engage in online social networking when they enter medical school, are open to discussing this presence, and, more important, are ready and able to edit and monitor their presence during the course of their training. Early education has the potential to make students partners and peers in the construction of meaningful guidelines and policy about appropriate social media use, both for educators and for institutions.28,30,31 It remains to be determined whether further curricula spread throughout training are needed to refresh students’ awareness of the need to monitor their online presence. Future studies should examine whether reinforcement throughout training is needed, whether the inclusion of more complex ethical and policy issues that involve patients in the curricula would reinforce learning, and whether curricula presented at different developmental stages by different instructors or mentors have different effects on students’ behaviors and attitudes.”

There are many other sources for training in Social Media, for the nuts and bolts of it all, and the ethical considerations.  One of the outstanding programs is the Mayo Clinic Residency in Social Media .


Sunday, March 10, 2013

Riddle Me This


Today I am  asking questions and taking no prisoners. I don’t know much about HIT I have decided that within 24 months I will know nothing about healthcare or the  systems that run it,  pay for it. I will not recognize any payers, medical groups, nor will I understand the new ICD-10 codes.  I imagine within 5  years you will not be using CPT codes, certainly not tied to billing or reimbursement. They will only  function for analytical  purposes.

When I graduated from medical school I was indoctrinated that I would have to update my skills frequently as the half-life of my data base was ten years.  Those teachers and professors were very optimistic. In most cases it is five years and in some cases perhaps one or two years.

Why has this happened ?  How do we deal with this explosion of knowledge? Our plight and fortunes in health care are not isolated issues.  How do other industries deal with this, and do they have the same magnitude of change, less, or more?

Why does the law of thermodynamics that states energy must be used to prevent organization from descending into chaos ?  Are we organizing or are we  creating chaos?

What are we doing?

How is it that the Office of the National Coordinator for  Health and Information Technology (ONCHIT) has worked with several standards organizations and has developed a certification program for interoperability among EMR vendors, and now we are reading about several EMR vendors who have agreed to a standard to make their software interoperable ????  What am I missing here?  Are they talking about a new and different standard, after years and expense of ONCHIT working all of this out.  The vast majority of current successful EMRs have adopted this standard by CCHIT, or ANSI or the        Group.

Is this all a joke?

I have no solutions, don’t look here. Whatever takes place will only be temporary at best.  This is human nature at it’s finest.

Best bet is  to maintain a sense of humor, as our friend the JOKER  demonstrates.


Friday, March 8, 2013

HIT and Sequestration


HIT has thus far survived several fiscal cliffs, a major recession, an election, and probably many things we don’t know about, yet.

For those who do not know about ‘Sequestration” this is all about it in a nutshell (no pun intended). Sequestration 2013 has occurred.  The effects yield about a 2% reduction in the Federal Budget. (by the way there is no budget). We have not had an official budget passed by Congress since 1997.  

When was the last time we had a budget bill that was approved?

April of 2009. But technically it was just an “omnibus spending bill,” and President Barack Obama was none too thrilled to be signing it, citing the excessive number of earmark projects. The following year, Democrats chose not to put forth a budget bill because they deemed it politically imprudent during the hotly contested midterm elections. Same thing happened the next year. You get the point. 

How will this effect health care outlays?

HHS Secretary K. Sibelius sitting to the right of President Obama as he discusses sequestration and it’s effect on health reform and PPACA

obama sequester congress

1. HIT incentive pays will be cut by 2%

2..Projected outlays for mobile health development will diminish by 2% as well. Reductions for the FDA will effect the FDAs program to certify and regulate mobile health applications in development.  Mobile health development during the past two years has grown enormously.  My assessment is that it will continue and not be effected much by not having the FDA supervising the ball game.  The market place controls this type of activity. There is no law stating that mobile health applications cannot be sold, but caveat emptor.  There may be some reluctance on VC money. Most serious developers like to know what they will be up against.

3. Medicare reimbursements will diminish by 2% as well.

The Hill reports sequestration will slash $ 11 billion USD from Medicare’s budget, take millions of dollars away from Affordable Care Act implementation programs.

Grants to help states establish insurance exchanges — new marketplaces for private insurance coverage — would lose $66 million, the administration said. The law's prevention and public health fund would lose $76 million

Congress exempted Medicaid and the Children's Health Insurance Program from the sequester, but other healthcare programs would have to absorb big hits.
The Food and Drug Administration would lose $318 million — more than 8 percent of its budget. And the National Institutes of Health would see a cut of more than $2.5 billion. Academics and other advocates for medical research say the NIH cuts would be devastating for medical science.

And it is even more important to realize this is not just a one year cut in spending. The cuts equal roughly $1 trillion over the next ten years and make significant cuts in defense, health care, and other government spending. Both parties are struggling to find common ground on how to replace these cuts with more politically and economically palatable ones.

The looming 2% sequester of Medicare spending to reduce the federal deficit could result in 766,000 fewer healthcare and related jobs by 2021, according to an economic analysis from three healthcare interest groups (PDF).

These facts are laid out by Modern Health, and The Hill.

And there will be secondary and consequential effects in employment (766,000 jobs) according to estimates

“The report categorizes the job losses as those having a direct effect on healthcare; those having an indirect effect, which reflects the impact of local industries buying goods and services from other industries; and those having an induced effect, which relates to the jobs lost when workers don't re-spend their income. In 2013 alone, the report estimates 496,431 fewer direct-effect jobs, 88,453 fewer indirect-effect jobs and 196,222 induced-effect jobs.”

Because health costs are now such a large portion of the Gross Domestic Product the relative 2% reduction of expenditure in Medicare outlay it will have a relatively greater effect on the overall economy, than a 2% contraction in another sector.

Thursday, March 7, 2013

Hans Rosling: Stats that reshape your worldview


Population health is much more easily explained by graphic presentations rather than tables, charts or pie charts. Let’s listen to Professor Hans Rosling. It’s an interesting show, with some surprising images of public health evolution.

I am one of those people that learn best from visual images, so for me this is spectacular !


It is All Changing, Not Just Health Reform


You have been a successful physician in your area of specialty. What now?

In the relative quiet before the storm, healthcare physicians and executives at all levels should take time to rethink their career management strategies.

This not only applies to physicians but to industry as well:

Here are some other career management questions that executives should consider:

  • Do you have the intellectual horsepower to master a business model change?
  • Do you have the skills – from excellence in verbal and written communications to the ability to create innovative new strategies – to benefit from regulatory, reimbursement and market shifts?
  • Are you prepared to make the tough calls on human capital development, investing in enriching your team and to move out those who do not measure up, regardless of the personal history?
  • Do you have the passion and the energy to do what it takes to focus on the internal operations while spending more time dealing with market-wide developments?
  • Are you prepared to make the life balance sacrifices, when necessary?  Do you have the discipline to know exactly when to pull back and re-think life’s priorities?

The next seven years will be unlike any we have seen in healthcare.  Before the upheaval begins, this is a good time to take a few minutes to ask:  “Is this what I really want to do with my life?”

Rob Lamberts M.D. The Master of his own fate… Dr. Lambert has always been an “early adopter”. Rob seems to anticipate the next paradigm shift or catalytic change in health care.


Monday, March 4, 2013

Health Care is not a Bank ATM


Many used to ask why they could go to a bank and insert a card and be able to do most of their banking with little effort.  The health care system bought into that concept and began constructing hardware and software to conquer the challenge.

Unfortunately Health Care is not a bank or an ATM.

The order of complexity in health systems which are based upon biological systems is almost infinite with this explanation given by Tim Cook and Dr. Luciana Cavalini's presentation at the OSS 2011 conference on multi-level modelling in healthcare.


Presentation at the 14th International Conference on e-Health Networking - Application and Services in 2012

Healthy Social Media Participation


Sunday, March 3, 2013

The Affordable Care Act Nobody Can Afford


Many people that Obamacare is now the law, there continues to be what is not a minority expressing their educated opinions that we are running to a catastrophic conclusion of this battle.

Although many point to the medical systems in the United Kingdom, Canada and elsewhere some in those systems are negative about the U.S.’s journey to Obamacare.

Canada Free Press

Among those are

Dr. Ileana Johnson Paugh, (Romanian Conservative)  a freelance writer (Canada Free Press, Romanian Conservative,, author, radio commentator (Her book, “Echoes of Communism, is available at Amazon in paperback and Kindle. Short essays describe health care, education, poverty, religion, social engineering, and confiscation of property. A second book, “Liberty on Life Support,” is also available at Amazon in paperback and Kindle. A third book, “U.N. Agenda 21: Environmental Piracy,” is a best seller at under Globalism, Politics, and Environmental Policy.

Dr Paugh reflects upon how this change in American Medicine will effect freedom.

The plight of the physician who took an oath to care for a patient is real. The law and the accoutrements surrounding it, with a myriad collection of electronic documents,consent forms, and permissions to share protected information with a broad sweep of one electronic signature amounts to an extortion of consent (without which the patient could be denied a doctor’s care. Unknowingly physicians have become unwilling accomplices rule by attorneys, and organizations more intent upon protecting themselves than helping a patient become well again.

Case in point:


I was just handed the Phreesia computer tablet by the receptionist under the guise of updating my medical and insurance information. I had seen this orange notebook in another doctor’s office and I became suspicious. Is this really meant to verify, as the website claims, my insurance eligibility automatically and help doctors collect on their insurance while easing the load of paperwork? Or is it forced electronic data compliance to Obamacare?

As soon as I started reading each screen, I realized that it was asking me to consent to third parties to obtain my medication prescription history from my pharmacy and to my entire medical history.

I had the right to request and restrict as to how my protected health information was used or disclosed. However, when I declined to sign, the computer stopped, and prompted me to talk to the receptionist. She informed me that diagnosis and/or treatment “may be conditioned upon my consent.”

The electronic screen and the paper copy the receptionist gave me said, “The [name withheld] is not required to agree to the restrictions that I may request and may refuse treatment based on my restriction as permitted by Section 164.506 of the Code of Federal Regulations.” 

Suddenly, because I refused the IRS and HHS meddling in my personal health affairs, I had become persona-non-grata (unwanted person) to my doctor who had sworn a Hippocratic Oath to care for me and any patient who comes across his/her path.

In other words, I would not be treated if I did not sign yes. I had the right to say no, don’t give my medical information and history to anyone else but the doctor is not required to honor my request and may refuse treatment to me as permitted by Section 164.506 of the Code of Federal Regulations. In other words the physician, or hospital representative becomes an enforcer of federal law. Taken out the context of real situations it paints a bleak picture of what freedom is not in the U.S.A.

Welcome to the destruction of our stellar healthcare and patient/doctor confidentiality, compliments of Obamacare.

How affordable is this Obamacare, the unfortunately named, the Affordable Care Act? The Democrats and the President said that costs would be so much lower; it would save the typical family $2,500 per year.

The cheapest category of Obamacare is the Bronze Plan which costs $20,000 per year for a family of two adults and three children and it pays only 60% of medical costs after the deductibles for the year have been met. And the deductibles are high per person and per family. The following tiers are Silver (70%), Gold (80%), and During my 30-year teaching career, Dr Paugh goes on to explain, “I seldom had to pay more than $3,600 a year premium for private insurance for my family. Even a retirement private plan did not cost more than $8,000 per year with 80% reimbursement as opposed to only 60% reimbursement under the Obamacare Bronze Plan. Is Obamacare really affordable? The answer is a resounding no.Platinum (90%).”

Everybody’s private insurance has been disrupted and private premiums have escalated,

The federal government has built a data hub to be used only for Obamacare without saying how it will be run. The HHS has released 13,000 pages of regulations with only 30 days for public comment while attempting to re-engineer 17% of the economy. (WSJ, It’s a Mad, Mad, Mad Obamacare, December 13, 2012)

On the deadline of December 14, 2012 states had to declare health insurance exchanges. At that time, only six states (Colorado, Massachusetts, Maryland, Oregon, and Washington) received conditional approval from the Department of Health and Human Services (HHS) to operate their own exchanges. Twenty-six states stated that they will not set up exchanges.

These items are only the tip of the iceberg now showing, the remaking portions (90%) lie below the water line ready to sink the ‘Titanic” of Obama care

More than $719 billion will be taken from Medicare over the next ten years to pay for Obama care. According to Rep. Wally Herger, Chairman of the House Ways and Means Subcommittee on Health, the Independent Payment Advisory Board established by Obamacare is authorized to unilaterally impose price controls and de facto rationing of medical care.

Medicare is already in trouble. Taking $719 billion over ten years from Medicare to fund Obamacare will exacerbate financial problems. Medicare benefits are not a return on taxes paid into the system over time because Medicare is run as “pay as you go” - today’s wage earners pay taxes to fund benefits for today’s retirees. Since people live longer, “Medicare payroll taxes cover only 38 percent of current benefits.” (Rep. Wally Herger)

The Canada Free Press elaborates further.

And this is from a Canadian Press. They are probably wondering, where do we go now?