I temporarily went back to paper records. And it wasn't so bad.

I temporarily went back to paper records.  And it wasn't so bad.



The real story. Hopefully his database is still intact.  The big question is why this cloud based EMR did not have a mirror which would allow for uninterrupted service.  Another important question for EHR cloud vendors is do they have redundancy in several data warehouses. Fire or other catastrophic events could effect thousands of physicians.  Any physician considering cloud based EHR should insist on this feature.

A refesher look at prior technology. We recomend always keeping some progress notes in the store room.  An alternative to typing in the hand-wriiten notes, just scan them into the EHR when ready. It is ill-advised to use a physicians time to transcribe data. There are many affordable scanners that are also scanning devices:

Hewlett Packard AIO Printer

In the overall scheme of things 20 medical records don't mean anything to the data geeks.

EHRs do afford more legibility and better data retrieval.

The Impact of Aging on the HCFA, HHS, and CMS

Older Americans with five or more chronic conditions incurred an average of $5,300 in prescription drug costs in 2008, compared to $1,230 for those with no chronic conditions. MORE STATISTICS

20 percent of total U.S. population  — The population of Americans age 65 and over in 2030 is projected to be 20 percent of the total U.S. population (72 million), compared to 13 percent in 2010.

SOURCE(S): Federal Interagency Forum On Aging Related Statistics

19.2 years of living after age 65  — Under current mortality conditions, people who survive to age 65 can expect to live an average of 19.2 more years, nearly 5 years longer than people age 65 in 1960.

1.3 years of more living   — Under current mortality conditions, white people who survive to age 65 can expect to live an average of 1.3 years longer than black people.

SOURCE(S): Federal Interagency Forum On Aging Related Statistics

45 percent of beneficiaries live with chronic conditions  — Nearly half (45 percent) of the Medicare population is living with three or more chronic conditions.

SOURCE(S): AARP

JUNE 26, 2012 One in four beneficiaries live below the poverty line  — Nearly one in four Medicare beneficiaries were living below the federal poverty line in 2007. SOURCE(S): AARP UNE 26, 2012 One in six beneficiaries under 65 qualified for Medicare on the basis of permanent disability  — One in six beneficiaries qualified for Medicare coverage in 2011 before turning 65 on the basis of permanent disability. SOURCE(S): AARP 21 percent of federal health care spending  — Federal spending for Medicare made up 21 percent of total expenditures in health care in 2010. SOURCE(S): Congressional Budget Office 80 million people covered by Medicare  — By 2030, 80 million people will be covered by Medicare. SOURCE(S): 2012 Medicare Trustees Report 65 percent in HMO plans  — Sixty-five percent of Medicare Advantage enrollees are in health maintenance organization (HMO) plans, followed by local preferred provider organizations (PPOs) and regional PPOs, 21 percent and 7 percent, respectively. SOURCE(S): Kaiser Family Foundation MAY 31, 2012 17 percent of adults aged 55 to 64 reported having unmet needs or delayed care  — Medicare seniors reported similar rates of unmet needs or delayed care (8%) to adults aged 55 to 64 with private insurance plans (17%). SOURCE(S): Kaiser Family Foundaion 165 provisions in the Affordable Care Act affect Medicare  — The Affordable Care Act contains roughly 165 provisions that affect the Medicare program. SOURCE(S): 2010 Medicare Trustees Report 2015  ANNUAL REPORT OFTHE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS Medicare Fraud Report from the OIG (2012) While Medicare Fraud is widely publicized,  cases were prosecuted in 2012, the OIGs report elaborates further. SUMMARY For the first half of FY 2012, we reported expected recoveries of about $1.2 billion consisting of $483.1 million in audit receivables and $748 million in investigative receivables (which includes $136.6 million in non-HHS investigative receivables resulting from our work in areas such as the States’ shares of Medicaid restitution). We reported exclusions of 1,264 individuals and entities from participation in Federal health care programs; 388 criminal actions against individuals or entities that engaged in crimes against HHS programs; and 164 civil actions, which include false claims and unjust-enrichment lawsuits filed in Federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters. Following are highlights of some of the significant problems, abuses, deficiencies, activities, and investigative outcomes that are included in the Semiannual Report for the first half of FY 2012. Health Care Fraud Prevention About 10 percent of money returned to the Medicare Trust Funds  — About 10 percent of the $20.6 billion obtained from people or organizations that committed Medicare fraud and returned to the Medicare Trust Funds since 1997 was returned in 2011. SOURCE(S): Department of Health and Human Services sent roughly 10.4 percent of GDP spending in 2086, resulting in greater strain on the federal budget, economy and Medicare beneficiaries. SOURCE(S): Medicare Trustees 2012 Report 15 percent of Medicare household budgets  — In 2010, health expenses accounted for nearly 15 percent of household budgets for Medicare beneficiaries, on average – three times more than non-Medicare households. SOURCE(S): Kaiser Family Foundation $78,000 average annual cost  — The annual cost of nursing home care averaged about $78,000 nationwide in 2011. SOURCE(S): Kaiser Family Foundation Graphics

Health Train Express is the Engine pulling or pushing ?

We all know that train engines can pull a train, or push from beind ?  The advantage of pulling the train is that the  engineer can see where he is going and where there might be obstacles on the track, a car, a broken rail, a rock, or any object that could derail  the train.  If the engine is in the rear...it pushes blindly, unless there is an observer in the first car. Perhaps a video monitor would suffice.

The analogy is about health care reform. Although many previoiusly uninsured now are counted as insured, this does not mean that all will receive health care.

The Affordable Care Act sets into play many steps on the journey of health reform. It looks like an all or none plan, destined to jump off the tracks at speed without considering turns or hills or obstacles. Thus far we have seen changes by executive order which have created concerns about the law being changed without congressional approval at the whim of the chief executive.  Most of it was do to poor planning on enrollment methodology, and some due to provider inability to comply in a timely fashion with the law.  None of this increases confidence in the law.

We in our daily work as physicians know all to well the working of our clinic and the work flow. We know  how and why claims are denied, the need for privacy and confidentiality and much more.

We have seen what digital health has done to privacy and confidentiality.

The complexity of our system has increased leading to more possibility for mistakes. The cost of the changes are being ignored in the calculation of savings.

Yes, the main driver of cost is utilization.

Who are the  drivers and sources for health reform ?

1. One can point fingers at state and federal regulators
2. The changes are so complex that it takes an army of consultants, who forever are holding meetings annually just to  assist providers with instructions on compliance. And here are some examples ofv groups and their agenda.

     CAPG               AGENDA 

   AMA This site from the Medicare News Group lists the portions of the ACA which the AMA      supports as well as those the AMA  opposes

FDA labels

In what may be a groundbreaking event, the constitutionality of FDA labels is brought into question, not by what is in the label, but what is left out.

Ethical, Legal & Social Issues
 Discussing off-label uses of drugs with doctors: a constitutional right or sidestepping the United States FDA authority?
  A Dublin based pharmaceutical company - Amarin Pharma, is currently in the process of suing the Food and Drug Administration of the United States for the right to talk about unapproved uses for their products as long as it is an honest depiction of the products capabilities. Even though some lower courts have agreed to this practice, the federal government in the United States have levied huge fines to some companies for talking to patients about off-label use for their medications. AmarinPharma is arguing that it has a right under the First Amendment (free speech) of the constitution of the United States to share certain information about its product with doctors. According to the lawyers for the company this is the first time a manufacturer had pre-emptively sued the agency over the free speech issue, before being accused of any wrongdoing. According to them “If you tell the truth — if you’re not misleading — then the First Amendment protects you when you provide this sort of information,”. But critics point out that this practice sidesteps the authority of the FDA, which is responsible for making sure that only safe and effective drugs reach the marketplace and that the constitution does not guarantee the First Amendment as an absolute right.
For further information 

A Glass of Wine is Equivalent to a Heavy Session on a Cross Trainer

Thoughts for #sciencefriday.



A glass of red wine is the equivalent to an hour at the gym, says new study |

 Drinking red wine could help burn fat, says new study
Research conducted by the University of Alberta in Canada has found that health benefits in resveratrol, a compound found in red wine, are equivalent to those that we get from exercise.

Red wine over a heavy session on the cross-trainer? Now that’s something we can definitely get onboard with.

According to lead researcher, Jason Dyck, these findings will help those unable to exercise as resveratrol was seen to improve physical performance, heart function and muscle strength.

“I think resveratrol could help patient populations who want to exercise but are physically incapable,” he says.

Not Runnning a Hospital

Paul Levy is one of my favorite reads....and he loves alpacas

His most recent post deserves some commentary, and for what it is worth..my history pre-dates his somewhat and all I can observe is that nothing seems to change...at all.

From “Not Running a Hospital (Paul Levy)

More Money coming in through the back door?

Robert Pear at the New York Times offers an excellent summary of findings by the General Accountability Office that the procedure used by the Medicare agency (CMS) to determine the relative weightings for $70 billion physician payments has major flaws.  That CMS weighting is also used by most private insurance companies as the basis for physician payments.  This is a topic that has received coverage over the years, but little has changed.

(A pause here to ask and refer back to a previous post:  When was the last time you heard one of the Triple Aim advocates—inside or outside of CMS--take on this issue, which has a direct result in how much primary care doctors and other cognitive specialists get paid?)

But, there is an important reminder in this story.  Pear notes (with my emphasis added):

“Under federal law, Medicare fees are supposed to reflect the time required to perform a service and the intensity of the work.”

Uh oh.  Let’s consider how the pervasive use of robotic surgery will factor into this calculation.  For example, in the past, most prostatectomies would have been done as open procedures or using a manual laparoscopic approach.

Now, due to a highly successful marketing campaign by Intuitive Surgical and by doctors and hospitals that have showcased their robotic surgery program, the vast majority of these cases are performed robotically.  This has increased the required time in the operating rooms.

The same applies to other procedures in which Intuitive has made and will make inroads—gall bladder removal, hysterectomies, hernia repairs, and so on.

Is this a back-door way for surgeons to receive more money for the same procedures?

POSTED BY PAUL LEVY AT 6/02/2015 11:18:00 AM

Health Train Express’s Response

Commentary on his blog post:

Dr. Levy, this is not an unusual or new problem:

Medical Device companies repeatedly create this type of disruptive innovation, created by an innovative medical bioengineer, and quietly pass along the problem to the MD who becomes the evil-doer.  In this case the increase in time due to the complexity of the surgery requiring significant expense purchasing the equipment retraining and other hidden costs should be adjusted upward.

A literature review from the   American Cancer Society  reveals the following:

“Robotic-assisted laparoscopic radical prostatectomy

A newer approach is to do the laparoscopic surgery using a robotic interface (called the da Vinci system), which is known as robotic-assisted laparoscopic radical prostatectomy (RALRP). The surgeon sits at a panel near the operating table and controls robotic arms to do the operation through several small incisions in the patient’s abdomen.

Like direct LRP, RALRP has advantages over the open approach in terms of pain, blood loss, and recovery time. So far though, there seems to be little difference between robotic and direct LRP for the patient.

In terms of the side effects men are most concerned about, such as urinary or erection problems (described below), there does not seem to be a difference between robotic-assisted LRP and other approaches to prostatectomy.

For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard LRP. Still, the most important factor in the success of either type of LRP is the surgeon’s experience and skill.

If you are thinking about treatment with either type of LRP, it’s important to understand what is known and what is not yet known about this approach. Again, the most important factors are likely to be the skill and experience of your surgeon. If you decide that either type of LRP is the treatment for you, be sure to find a surgeon with a lot of experience.”

In another specialty such as ophthalmology, cataract removal underwent many changes requiring more expensive equipment, such as phacoemulsifiers, femtosecond lasers, yag lasers and more.  These changes resulted in a shift to an ASC for a  fifteen minute surgery, vs a three day in patient procedure taking one hour.  Medicare slashed the allowed amount from $1300 for the physician fee to about $ 500.00.  The overall change improved outcomes greatly, reduced hospital stay (eliminating it completely in most cases)

One must not forget that the reimbursement includes time for post-operative care, up to 90 days in the case of cataract surgery, which is truly neglected in the case of cataract removal and most likely also LRP or RALRP.

The truth is that CMS is bloated with bureaucracy and needs to be investigated by an inspector general.  We have too many parastic entities feeding off the chaos of CMS , the Affordable Care Act and burgeoning health reform.

Competitive Harm From State Licensing Boards: First North Carolina Dentists, Now Texas Physicians?

Changes in health care and health administration are taking place at a rate that does not allow for all parts of they system to remain in synchrony.  Frequently our health system as in many other areas of government intrusion progresses quicker than regulatory agencies can adapt to modern health policy.

Medical Boards also must react to changing practice patterns.. Technology is a great disruptive influence (one which I prefer to call 'catalytic innovation).

Our title today exemplifies the interactions between regulatory boards and the judicial process. They often do not work harmoniously as this case from North Carolina and Texas illustrate. These cases also illustrate conflict in interpretation of law enforced by the Federal Trade Commission, and adjudicated by our legal system.

Which takes precedence ? Standard of care, or anti-trust activity.   These two disparate concerns often conflict in health care, as
 'consumerism' invades professionalism.

The pace of technical innovation is driven by real necessity, to improve quality.efficiency, and to lower costs.

THE UNSEEN WAR ON TELEHEALTH

Or, what do these nine stone men have to do with telehealth ?

What should be a new era of medical board governance has begun with what looks more like a finger to the eye of the U.S. Supreme Court. On May 22, a federal district judge in Austin, Texas heard arguments to determine whether a rule adopted earlier in the month by the Texas Medical Board should take effect on June 3. No decision on a temporary restraining order has yet been issued, but the hearing offered a preview of litigation likely to arise under federal antitrust law as it was recently clarified by the nine justices.

The dispute in Austin pre-dates the Supreme Court’s ruling. For several years, the Texas Medical Board has been in litigation with Teladoc, a Dallas-based company that contracts with licensed Texas physicians to provide telephonic consultations to patients in the state. Teladoc physicians sometimes prescribe medications during those sessions, a practice that the Texas Medical Board has attempted to eliminate by an increasingly stringent set of interpretations and amendments to its longstanding Rule 190.8, which quite reasonably prohibits prescribing unless a physician-patient relationship has been established.

At the hearing, however, the fact that the Teladoc litigation had morphed from administrative law to antitrust law was lost on the Texas Medical Board’s lawyers. Based on the case it presented, the Attorney General’s office seemed unclear on the concept of competition being unlawfully hindered by licensing board action. The Assistant Attorney General arguing on behalf of the Board brushed aside Teladoc’s challenge on the ground that “practitioners are always looking for new avenues of attack on regulation,” and even claimed it was “kind of a distortion to be talking ‘business’” — entirely missing the point that established practitioners were being accused of abusing their regulatory privileges to insulate their existing business models from competition.

The Board still inexplicably allows “on-call” physicians covering for patients’ regular physicians to prescribe medication after a phone call. As the judge in Austin observed, there has to be “something more than ‘we’re doctors, trust us.’”

Only the Texas Medical Board knows why it adopted this particular rule at this particular time. It seems doubtful that preventing competition was its major goal. On the other hand, the rule doesn’t seem necessary to protect patients either.

And to add to the confusion how does state law interact with federal statutes ?

Does state sovereign immunity under the 11^th Amendment to the Constitution constrain or prohibit suits for injunctions or damages involving bona fide state agencies that the federal antitrust laws now treat as private parties? (Teladoc sued the Board as a whole, and also sued each of the Board members who voted in favor of the new rule both as individuals and in their official capacities.) How will plaintiffs prove “antitrust injury” when action is being taken by a licensing board rather than by entities with whom the plaintiff is doing or wants to do business? Will these legal hurdles be easier to surmount when a board has adopted a blanket rule involving many potential competitors, as opposed to taking disciplinary action against a single competitor?

Stay tuned.

Medical Professional Re-Boot for the 21st Century

During the past two decades medicine has undergone a re-boot process.

At first most physicians were reactive rather than pro-active regarding quality improvement measures. A whole new vocabulary of medical eponyms rapidly developed to explain previously unrealized power of health information technology.

Some changes also impacted heavily upon medical ethics and standards of care. Many previous practice routines became obsolete, to be replaced.

Young physicians will have little difficulty with the new system because they were born and raised with the new technology and ethics.  Mid-career and late-career MDs will at first struggle with the transiton process.

Organized medical groups, the AMA and specialty associations have promulgated new guidelines and preferred practice patterns for physicians.

The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.

Fundamental Principles
Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

Medical Professionalism in the New Millennium: A Physician Charter

The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.

Live stream from San Francisco May 29 ,2015 9:00 AM

Health Train Express stopped at Moscone Convention Center to take a break from Health Reform, Health IT and the never ending conflict of practicing medicine.  Hopefully this will be a period of recreation and re-vitalization.

For those of  you who tuned in yesterday,  you found us a Google's i/O, their annual exposition in San Francisco to display and deep dyve into their latest advances and new entries in the android space.

If you are here and you managed to get up after a night of carousing the shebang starts at 9:00 AM PDT.

Here is a  photo montage of yesterday's extravaganza in the big hall. The pre-keynote show included a galaxy size game of Pong.

Google I/O  May 28, 2015

Today there are a large number of events, and breakout sessions. I have to make some diffiicult choices, as well will you.  Yoda is sitting right next to me this morning, and I feel the FORCE .

Much of health care now involves mobile apps and Google' android phones and tablets are already playing a large role in many of your practices.

For those of you who are still working in 2000 this is your chance to catch up.  Open your window, take a deep breath and pretend you are here with us in San Francisco.

ACCUWEATHER FOR SAN FRANCISCO

Google I/O 2015

Google I/O 2015



Live stream from San Francisco  May 28,2015  9:30 AM

Health care will benefit from "mhealth". on Android, wearables, remote monitoring, health messaging.

Automobile manufacturers:  Volkswagon, General Motors, Audi, Hyundai Sonata, Ford, GM, Mitsubishi
35 auto manufacturers

Television: Sony, Phillips, 

4,000 devices, 'be together, be the same '  400 OEMs, 500  carriers, 

Leave no one behind.

Android wear

Android TV: Sony, Sharp, Chromecast, 17milliion devices HBO  Streaming consoles, 

M developer Preview:  Customized with selective app permissions before activation. and ability to revoke specific permissions.

Web Browsers:  Custom tabs sign in  saved passwords  autofill  security

Android pay   Near Field (NFC)  DESIGNED TO NOT USE ACCOUNT NUMBERS
   Over 700,000 retailers, VISA, DISCOVER, AMERICAN EXPRESS, MASTERCARD

   Fingerprint standardized identification


Android Watch  LG   

Check back tomorrow here on Health Train Express