Participatory Medicine

There is a new eponym about to erupt in health care  PM. which is short for Participatory Medicine.

Participatory medicine: A high-tech alliance with patients

 

Charles Smith M.D., who blogs at eDocBlog, tells a story,

Matthew Herper’s post about thalidomide treatment of Myeloma is a good example of how patients will contribute to medical knowledge in the future, and may form a cautionary tale for patients who get involved to this degree in formulating new treatment approaches.
I work with Bart Barlogie, MD, (quoted in the article as the physician who ran the first clinical trial of the use of thalidomide in treatment of Myeloma) who is an innovative clinician researcher who has extended the life of many patients with Myeloma with his treatment approaches. He is also treating my wife who was diagnosed three years ago with Waldenstrom's Macroglulinemia, a form of lymphoma that resembles Multiple Myeloma (she has responded very well to his treatment).

The fact that her husband pushed her physician to try a novel approach to try to save his life, and that it was tried (even though it didn’t work for him), is an example of what will happen increasingly in the “new world of

Participatory Medicine”.

He would undoubtedly be cheering with the knowledge that the treatment that helped him beat back his disease for over a decade was probably “discovered” by a patient who was practicing Participatory Medicine!

Participatory Medicine: Patients doing research, usually online, and taking the ideas into the medical arena. Get ready, it’s going to be a brand new world!

Dr Smith, I can’t disagree with your assessment, but this is not a new phenomenon, such as the new world order.  It has been going on for decades as far as I know.  I was exposed to this each day in my practice. PM is just a new eponym for an old process.  I’m certain Dr. Smith already knew this, but gives it a new name to draw attention to this for patients.

What is different in 2011 is that doctors are much busier seeing larger numbers of patients, and face time is markedly reduced, so that patients must be encouraged and pro-active to ask questions that are directly focused on their own problem.

What is also different is the growing use of EMRs. In  the past, physicians  would adjust their examination (and history) on relevant answers or findings on the physical examination based on their knowledge base of information built on years of clinical experience. Much of the process was fast and unconscious, and based upon previous learning and experience, much as we all experience such as riding a bicycle.

The current generation of EMRs does not allow tree analysis of the history and examination, truncating the process into usable information. The physician or assistant is forced to enter much useless information.

What our current EMRs produce is an endless repetitive list of information, which may be more readable but is offset by the prodigious meaningless amount of data.  Most of this information will never be read, again.

The amount of processing power would be awesome to develop the tree analysis to structure a meaningful history and  physical examination,and. probably too expensive unless it was rendered in the ‘cloud’.

Technorati Tags: emr,participatory medicine

Doctor, Do I Need This CT Scan ?

 

In a rather frightening statistic, it has been stated that anywhere from  1 in 250  to 1 in 80  patients who undergo  CT scans will develop cancer.  These  are numbers extracted from studies in the U.K and U.S.A. 

However these global statistics are almost meaningless for an individual patient, and exemplifies the idea that statistics can be manipulated easily to make a point or gain advantage.

For instance Spiral CT scans have resulted in early detection of lung cancer and a 20% reduction in death from lung cancer.

Certain CT scans can increase the radiation dose by a factor of 3X or more.

Having a CT - or CAT - scan puts patients at far greater risk of developing cancer than previously thought, scientists claim.

The radiation generated by the scans - an increasingly popular diagnostic tool - may trigger the disease in as many as one in 80 patients.

This is far higher than the often used figure of one in 1,000 - with women at particular risk as they are more sensitive to the effects of radiation.

Researchers now believe the dose of radiation delivered by a CT scan can vary wildly according to where on the body it is used.

In some cases, they suggest, a single scan can be the equivalent of 442 chest X-rays.

Unlike an MRI scan - which uses magnetic fields and radio waves and has no known harmful effects - a CT scan generates ionising radiation so each dose causes a slight increase in the lifetime risk of cancer.

The scans allow doctors to build detailed 3D images of internal organs, blood vessels, bones or tumours.

They were already known to carry a greater risk than ordinary X-rays, such as those used for breast screening, but the latest research suggests a bigger problem.

It found the dose of radiation received was larger than thought, although this varied according to the part of the body being scanned and the age and sex of the patient.

The researchers concluded there was an average 13-fold variation between the highest and lowest doses experienced by patients, says a report in the journal Archives Of Internal Medicine.

University of California Professor Rebecca Smith-Bindman, who led the study, said: 'The risk associated with obtaining a CT is routinely quoted as around one in 1,000 patients who undergo CT will get cancer.

'In our study, the risk of getting cancer in certain groups of patients for certain kinds of scans was as high as one in 80.'

1  = 442 

The typical dose delivered by a single CT scan was the equivalent of 74 mammograms or 442 chest X-rays, the professor said.

Researchers reviewed 1,119 patients in San Francisco who had been scanned in three body areas - the head and neck, the chest, and the abdomen and pelvis.

The scientists then worked out the radiation dosage of each scan and estimated the associated lifetime risk of cancer.

A heart examination might involve three scans, looking at different phases of the pumping cycle.

Prof Smith-Bindman said: 'This increases the information that we can get from the CT procedure, but increases the radiation dose by a factor of three.'

They were already known to carry a greater risk than ordinary X-rays, such as those used for breast screening, but the latest research suggests a bigger problem.

It found the dose of radiation received was larger than thought, although this varied according to the part of the body being scanned and the age and sex of the patient.

The researchers concluded there was an average 13-fold variation between the highest and lowest doses experienced by patients, says a report in the journal Archives Of Internal Medicine.

The scientists then worked out the radiation dosage of each scan and estimated the associated lifetime risk of cancer.

She said doctors need to reduce unnecessary use of scans.

Technorati Tags: ct scan,cat scan,cancer rate,lung cancer

Mike Leavitt: Health reform’s central flaw

Mike Levitt, the former Head of HHS reflects accurately what Congress has allowed in Obamacare.  Among other observations he notes the following in his commentary in the Salt Lake Tribune.

It puts more power than is prudent in the hands of one person, and it is not an answer to our national health-care crisis.

Set Up to Fail…..Just say no,  Katherine.

Mr. President, I am performing a “tooth level surveillance’ as instructed in Obama-care.  I am sorry to report you are in violation of dental dictates.

Shortly after being appointed to the Cabinet in 2003, I sought the advice of  one of my predecessors. He cautioned me to be prudent in exercising the considerable regulatory power Congress had granted these offices, noting: “The place has more power than a good person needs or a bad person ought to have.” 

It puts more power than is prudent in the hands of one person, and it is not an answer to our national health-care crisis.

Examples of that astounding power include tooth-level surveillance. That’s in Section 4102 of the health reform law says, “The secretary shall develop oral healthcare components that shall include tooth-level surveillance.” It defines tooth-level surveillance as a clinical examination in which an examiner looks at each dental surface on each tooth in the mouth.

This determination is better done by a dentist.

There’s more: The health-reform law dictates that the secretary shall determine how drugs are dispensed at long-term care facilities, shall identify categories and classes of drugs that are of clinical concern and shall be permitted to use comparative-effectiveness research to determine coverage and reimbursements. The 2,700-page law has nearly 2,000 of these “the secretary shall” statements.

If I may, as a former HHS secretary, offer a suggestion to the current secretary, it would be this: Use these expanded discretionary powers to grant states and the private sector more flexibility and more autonomy. Competition, innovation and new models of providing care and expanding coverage are the only ways we will reverse the dangerous course of future health spending. That simply cannot be done from Washington.

Please read the article…..it will confirm what we all say.

Perhaps Mike Leavitt should return to HHS…

Technorati Tags: Mike Leavitt,Katherine Sibelius,Obamacare,HHS,dental

Foreign Perspective on US Health Economics

I write for a financial newsletter on  Mergers and Acquisitions.   The M&A market during the first two months of 2011 has been sizzling. And the world markets have been watching the U.S. closely. Goldman Sachs, fueled by   bail-out bucks has fueled predatory acquisitions by huge IT internet social media concerns of startups and sizeable going concerns.

Foreign analysts,SVP Eric Paternoster gave a presentation at the 2010  Infosys Analyst meeting……about the Healthcare Economy in the United States.In health care, hospitals are merging to form large health systems. This movement is occurring  because of realistic fear  of governmental mandates to form ACOs and the necessary capitalization of digital transformation, new administrative requirements for reimbursement, and operational considerations about outcomes, quality improvement and fear of rampant destructive competition. Regulators are hot at work determining which mergers will cross the line of FTC regs. It’s a great time for lawyers.

The reality of the finances are that even if American Medicine is not nationalized, by defacto, large monopolistic organizations are blooming.

 

Physicians need to keep up with these seemingly non health related issues, because it will effect both small and large practices, alike. At the end of a given day, tired, exhausted, financially depleted, overwhelmed, discouraged and depressed physicians may just roll over and go with the flow. In the stream of daily activities of  physicians, malpractice worry's, CME requirements, credentialing requirements patient care, Medicare worries, declining reimbursement, and the overall intrusion of insurance companies, demands for better outcomes, and general interference in their responsibilities for patient health and lives, who would not roll over, or change careers.

The malaise has trickled down to medical students, just beginning what used to be a privilege of authority granted only to those with ultimate responsibility for patient welfare. Today we are faced with demagogues in health care, the Sebelius’, the Berwick’s, the health care foundations, and all those wannabees who are sabotaging health care with politically correct statements. They come, they go at the end of the day we are left with the remains.

Technorati Tags: health economy,health mergers,physician burnout,health analyst,hospital mergers

Message in a Bottle

 

UV Blockers May save your life, or at least from a scar.

News about Laser ID-ing Skin Cancers

How to Check for Skin Cancers

 

New blog follower:  Check out the Blog Friends Roll.-

Technorati Tags: melanoma,basal cell,squamous cancer,uv blocker,lasers,self diagnosis

Over the Horizon

The very recent success of IBMs Watson Computer signals not only the beginning of advances in computer intelligence but the announcement that IBM is about to  embark on disciplines such as healthcare. The one million dollar prize, which Watson earned playing Jeopardy for IBM, is being donated by IBM to a charity.  Watson beat two of the show’s most successful and celebrated contestants – Ken Jennings and Brad Rutter – to win a $1 million grand prize that IBM donated to charity.However, the Watson experiment indicates how truly important artificial intelligence and natural language processing can be for all kinds of business uses, including health care, law, call centers and a lot more.

IBM created Watson as part of the company’s effort to help business make sense of the explosion of data. Watson can analyze the meaning and context of human language and rapidly process information to find more precise answers to questions posed in natural language. IBM maintains that this holds enormous potential to transform how computers help people accomplish tasks in business, communities and their personal lives.

For you  techno-geeks the hardware looked like this:

10 racks (about 90) of IBM Power 750 servers with 2880 Power7 cores capable of running at 80 teraflops, 500 GB per second on-chip bandwidth, a 10 GB Ethernet network, 15 terabytes of memory and 20 TBs of clustered disk storage. Watson evaluated the equivalent of 200 million pages of content – or about 1 million books’ worth – written in natural human

The research and technology initiative will combine IBM’s Deep Question Answering (QA), Natural Language Processing, and Machine Learning capabilities with Nuance's speech recognition and Clinical Language Understanding (CLU) solutions for the diagnosis and treatment of patients that provide hospitals, physicians and payers access to critical and timely information. The two companies expect the first commercial offerings from the collaboration to be available in 18 to 24 months. IBM and Nuance will jointly invest in a multi-year research initiative targeted to the applications of the Watson technology to assist in the diagnosis and treatment of patients in combination with Nuance’s voice and clinical language solutions. In addition, IBM has licensed access to the Watson technology to Nuance. IBM and Nuance are currently engaged in a five-year joint-research initiative designed to advance next-generation natural language speech technologies, the results of which will be commercialized by Nuance.

Much of this work has already been accomplished on many smartphone applications. Nuance and IBM will continue its longtime collaboration with speech-recognition software developer Nuance Communications to bring the analytics capabilities of supercomputer Watson into the health care field. Nuance will feed its CLU (Clinical Language Understanding) applications into IBM's Watson hardware.

Jonathan Yarmis, an independent industry analyst known as Doctor Disruptive for his focus on disruptive technologies, likens IBM’s Jeopardy success with Watson to President John F. Kennedy’s pledge of putting a man on the moon.

Moreover, Yarmis said, “The health care announcement with Nuance is just Step 1. Given Moore’s law, in five to seven years this [Watson-like capabilities] is something your standard desktop computer will do. And two years after that it’ll be on your tablet and on your cell phones the following year. This statement is highly ambitious and goes where no man has gone before…predictions such as this have been laid fallow in the past.

However, without dreams there is no progress. Who would have predicted a handheld phone would have more computing power than early desktop PCs?

My bet is that it will all fit in a watch or a ring on your little finger .

Technorati Tags: moore's law,ibm,nuance,speech recognition,smartphone,watson

Teamwork and the EMR potential

 

Numerous experts discuss the importance of teamwork to an enterprise for efficiency and safety. In healthcare this concept is a relatively new one in the clinical setting. EMR has many potentials and/or shortcomings in this regard and it will depend upon design and user interface optimization to reach it’s maximum potential.

Bob Wachter presents a scenario and back ground for discussing safety culture in medicine, such as the built in hold for surgeons to verbally perform checklists with other staff, such as sideness of surgery, type of surgery, and other important data with the support staff.  These are all designed to minimize or eliminate ‘never events’ like wound infections, wrong side surgery, wrong organ removal, and administration of medications to which  the patient is allergic.

These safety features can be designed into the record with visual graphics, such as an image of the body with a circle or X through the body part to be operated upon. Visual images are processed more readily than printed words, which are often lost in a jumble of letters, even if bold-faced our distinguished by a red color.

Team work can be enhanced by Vector Diagrams or simple block diagrams with participants and specialist each integrated into the overall flow sheet, rather than a list of consultants or tests. Transformation of events and participants should be automatically transferred to such diagrams without human input.

There are many readily appications which perform these actions in other industries and software applications available on the internet, to wit: 

Visual thesaurus: (type in a word)  This application builds a    word map, much as your brain does for many tasks.)  The display is intuitive giving instant meaning to relationships.  This usage of the application could easily be adapted to professional resources and the team for each patient in a hospital setting. For very ill patients with multiple system issues this can be very complicated. The Virtual Consult Manager ferrets out key relationships easily seen by all participants in the team. Each segment can display as much or as little of the information in that segment. The circles can be clickable and take one straight to the relevant data for each team member.

The Map can be structured in a hierarchal, chronologic, spider, cluster or other organizational aids.

There are SDK for development of the map for other industries that interface with languages inherent in EMR, such as XML, CSS,

A few examples:

Now imagine these images as dynamic and fluid with changes in relationships. The user would be able to ‘pull out’ each button to see further breakdowns in organization, plans, and treatments. 

You can trial this at Visual Thesaurus

Who is Reading Your Medical Records?

Technorati Tags: hipaa,security,emr,hie,ehr,encryption,hhs,breaches

Privacy and Confidentiality issues are now out the physician’s domain and responsibilty.

Not surprisingly FierceHealth IT reports  that security breaches of personal health information is widespread.

Although paper charts were cumbersome, they were locked up at one location, not floating around in cyberspace.  I am sure these charts were read by others not authorized to do so, however it was near impossible to document this occurrence.

Today we have IT whereby access to medical records can be tracked and the burden for keeping it safe largely now lies with non-medical personel.   Pandora’s box was opened, with the use of EMRs,HIEs and HIPAA has lost the keys.

The situation will only worsen with implemention of health information exchanges.

FierceHealth IT reports

Hackers and other malefactors steal a surprising amount of personal health information by breaching computer security. Between August 2009 and December 2010, the electronic health records of more than 6 million individuals were compromised, and 61 percent of those security breaches were the result of malicious intent, according to Redspin, a leading provider of HIPAA risk analysis and IT security assessment services.

The Redspin report focuses only on breaches involving more than 500 people, which must be reported to the Department of Health and Human Services. This report is limited to breaches involving more than 500 people as required by HIPAA regulations.

The breakdown of events:

Business associates accounted for 40 percent of all the records breached. But that percentage, too, might be larger than reported. Although business associates are required to report breach incidents to healthcare providers within 60 days of their occurrence, it's not hard to imagine situations in which they fail to do so.

The report found that the security breaches occurred in 43 states, Washington, D.C., and Puerto Rico. Each breach affected 27,000 people on average, and breaches involving laptops and other mobile devices impacted on an average of 66,000 people. The latter accounted for 44 percent of all incidents and 65 percent of all records breached, suggesting that the theft or loss of mobile devices is as major a reason for breaches as hacking.

The cost of these breaches to the HIT systems goes far beyond the hardware and software systems put in place to secure the records as seen in this typical scenario which FierceHealth documents.:

Enforcement of breaches is a nightmare to all concerned in regard to notifications. All suspected people whose records were breached must be notified by HHS, after the breach has been reported, One breach must be assumed to involve all records compromised.  So the problem is multiplied enormously with the requsite expense of notifications. The enforcement burden on HHS and/or Justice, obviously strains the system and probably has not  been accounted for in the cost of  health care. 

Even unintentional breaches can be triggered by an innocent clerk entering the incorrect data field on a mailing list.

We learned last week that a contractor to the University of Texas Medical Branch in Galveston waited more than a month to inform the health system that an employee now in jail on charges of identity theft had access to records of more than 1,200 patients. And the California Department of Health Care Services sent out 50,000 letters with the recipients' Social Security numbers printed on the mailing labels.

HIPAA  has been modified to have a “threshold factor” and organizations are not required to notify HIPAA if no harm has been done. That proposition involves proving a negative, a conundrum and catch 22 if there ever was one.

One CEO expert offered that putting the key on the gateway should also have ‘shredding” of the records by simple effective encryption techniques. That would seem obvious to anyone.

According to Fierce Health the CIOs of every health organization from hospitals, to nursing homes are on alert ! There are dangers here when a politically motivated attorney general may decide to go after a hospital to enhance his reputation.

Read more:

Security officers have new motivation to protect healthcare data – FierceHealthIT

 http://www.fiercehealthit.com/story/security-officers-have-new-motivation-protect-healthcare-data/2010-02-16?utm_medium=nl&utm_source=internal#ixzz1E2wgZLS0

Telecommute Week February 14-18

 

This week ask your patients to stay home and tele-complain and have tele-treatment.  How about tele-reimbursement and/or tele-admissions, and don’t forget tele-surgery all you tele-docs.

I found this article on Gigaom.

Did you know that next week, February 14 through 18, is Telework Week? Companies and individuals are challenged to telecommute 1 or more days next week as a way to increase productivity, save money, reduce environmental impact and help employees achieve a better balance between work and life. I’ve gathered a few data points to help you convince your manager to embrace telecommuting, whether that’s during Telework Week or any other time of the year.

In general, the people who telecommute tend to be well educated with a college degree, in a higher income bracket and around 40 years old according to WorldatWork. The report went on to say that the number of telecommuters continues to increase, due to improved home Internet connectivity, increased fuel and commuting cost, and companies embracing improved work-life balance initiatives.

According to the Telework Research Network, if the 41 million Americans who hold jobs that could be done from home chose to do so for at least one day next week, the savings would be $772 million dollars in total, including:

• Commuter cost savings of $494 million
• A savings of 2.3 million barrels of oil totaling $185 million
• Traffic accidents reduced by 775, for a savings of $93 million

Companies can save over $6,500 per employee if that employee telecommutes just one day a week. Citrix Online is saving $2 million dollars in physical space costs by reducing seats in its office by allowing employees to work remotely.

Access Economics estimates that if Australia had a 10 percent increase in the number of people who telecommute for 50 percent of their worktime, the country would gain over $1.4 billion AUD per year ($1.4 billion) with reduced time and costs for travel, lowered office expenses, better employee retention, infrastructure savings, less fuel used and more.

Even the United States government is embracing telecommuting. Employees in the General Services Administration (GSA) are joining up with government agencies, companies and other organizations to pledge to telecommute at least one day next week. According to the GSA, about 50 percent of employees telecommute at least once a week already, which “leads to real estate cost savings and increased productivity, and helps reduce the agency’s environmental impact.” Telework Research Network claims that the Telework Enhancement Act of 2010 could result in a $15 billion a year savings for United States taxpayers with agencies saving $850 million in real estate costs and $2.3 billion in absenteeism every year while employees save up to $2700 in transportation and other work expenses and have fewer illnesses.

Whether you work for a small business, a multi-national corporation or a governmental agency, the benefits associated with telecommuting are similar: better balance and quality of life, reduced cost savings for both the employee and employer and a smaller environment footprint.

What are you going to do for Telework Week?  I am tele-sleeping..

Technorati Tags: telecommuting

Sunday Morning (very early)

Similar to what we read daily in regarding to health care I found this tidbit regarding another unintelligible, inexplicable and mysterious document dated back to the 15th century,  long before Medicare, HMOs, and ACOs

We are not unique !!  Someone from a far distant and unknown galaxy comes this story !!

Mysterious Ancient Document  Reveals – Nothing !

Technorati Tags: mysterious,ancient,cms,hmo,aco

Don Berwick vs Congress

 

Don Berwick MD must have been on call last night.  His testimony at the  Senate Ways and Means Committee was a good thing for those wanting to repeal the Health Reform Law.

When faced with specific questions regarding the costs of reform, and it’s impact upon availabilty of care providers he failed to deliver answers, stating that was not his area of expertise.  It’s obvious Dr. Berwick never ran his own medical practice.  He seemed more bent on the propaganda and rhetoric of the Obama administration, Nancy Pelosi and Harry Reid..

It unfortunately does confirm that some doctors know bupkas about finances. and not just those in private practice.

 

He even went so far as to tell the committee that they would like the system once it was in place for several years.  Most of the changes will not occur in 2011 and only begin to create an impact in 2013.  I agree with some of the utopian ideals that Dr Berwick espouses, however it is obvious that neither side has drilled down on the impact of true costs to patients, employers, or care providers  The bureaucracy will be stultify everyone concerned.

Even Berwick states that early predictions are way off. 

The healthcare reform law, beating the Medicare actuary's predictions, has so far strengthened the privately-run Medicare Advantage program, Medicare chief Don Berwick testified on Thursday. Enrollment is up six percent while premiums are down six percent, Berwick told the House Ways and Means Committee.
The Centers for Medicare and Medicaid Services actuary had predicted that Medicare Advantage enrollment would drop 7.4 million over the next few years - starting this year - and that premiums would rise. Berwick said the initial results show that the prediction was incorrect. "I have the facts on the ground before me now," Berwick said. "The facts are that Medicare Advantage is looking stronger and stronger."

Can it keep up?: Berwick said he doesn’t know how long Medicare Advantage plans will continue to grow. “It looks like the industry thinks there’s a good future for Medicare Advantage,” he said, adding that he hopes it will keep expanding or at least stabilize.

So how can anyone predict where this will be in 2020 ?

High-risk enrollment low: If Medicare Advantage was the good news for the Department of Health and Human Services on Thursday, then high-risk insurance pool enrollment was the bad. Enrollment over the past three months is up 50 percent to 12,000 - well short of the 375,000 originally predicted by the end of 2010. HHS said the low enrollment is consisent with the experience of the Children's Health Insurance Program, and they unveiled new tools on Thursday to help boost the high-risk program's visibility.

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Dr Price Tears into Don Berwick (CMS)

A live web video from the hearing on Health Reform Repeal Legislation.

Web Video Live

Rep.  Tim Price M.D.

You listen, you decide,  but a must view for everyone.

Google Health What’s Wrong With It

See all those ‘blue letters’  they don’t print.

In the hope that someday it might save me or my family some time (or maybe my life)  I have been entering medical data into GH the past year or so.

Yesterday my wife has a doctor appointment and I went to health.google.com and logged in. I reviewed the data.  It was easy to read online.  I decided to print it and take it with us to the appointment.

As usual when going to the doctor one is rushed, so I clicked on the pdf tab and print and walked off.  As I was running out the door and driving to the doctor I glanced at the print out. Much of it was blank, and'/or unreadable.

Now you may ask why. Why? Because Google was intent on making a ‘pretty display’ of basically boring data.  So a great deal of it was in color, blue to be exact, which does not print at all on B&W printers (which many people have if they use a laser printer, or more likely a deskjet of MFP which has an empty color cartridge (which mine did ).  I will bet you a buckwheat that most people have an empty color cartridge (because they are too expensive, and not really needed 95% of the time.

So Google if you are listening and not busy searching, please fix your Health web site so it is not useless for many people.

Technorati Tags: blue,print,google health,black and white,laser printer,mfc,deskjet