The Berwick Boondogle

This post is highly opinionated and biased, the opinions are solely those of the author.

In a letter today to President Obama, 42 Republican Senators requested the withdrawal of Don Berwick’s renomination to head the Centers for Medicare and Medicaid Services.

Dr. Berwick, a respected academic pediatrician from Harvard and the President of the well known Institute of Medicine was appointed by President Barak Obama hastily without congressional confirmation hearings. Berwick, who undoubtedly is a smart physician, but naïve about politics,and one who has misread his national colleagues opinions on health care hails from the Commonwealth of Massachusetts, where all intelligent  life exists only within the confines of route 128 (the Boston Beltway). Those who live inside Route 128 knows what is best for all of medicine, and health in the United States. Harvard, the beacon of light in medicine and science seeds the country, and universities with professors, teachers and sends leaders in academic medicine and many other disciplines  throughout the United States and the rest of the world.

Dr. Berwick fell on his sword with the following speech given at the NHS last year, just prior to his appointment by Obama.

Don Berwick MD speaks at the NHS

So it was a big surprise (to Obama) when Berwick  received little support from the grass roots of medicine, who  care for the electorate.

There was a rather humorous incident the other day at a National Journal event with Don Berwick, the man who President Obama hailed as being at the forefront of introducing “innovative technologies” into health care reform.

“Withdrawing Dr. Berwick’s nomination would be a positive first step in rebuilding the trust of the American people. The occupant of this important position, which affects the health care of so many Americans on a daily basis, requires an individual with the appropriate experience and management ability. Our seniors and those who rely on Medicaid deserve no less,” the Senators write.

While Dr. Berwick has been renominated for the position, as Head of CMS, for which he was a recess appointee last year, no hearings have been scheduled yet regarding his nomination.

del.icio.us Tags: cms,head of cms,berwick,congressional confirmation hearing,nhs

Health Care EMR & The Cloud

Healthcare, EMR and the Cloud

The Health Train Express exits the tunnel of meaningful use into the cloud.

The future for digitization of health records is cloudy.

This next decade will see a transition from client-server to solutions based in the cloud. The cloud is the virtual space located on a powerful server at a distant location.

It will facilitate adoption of more robust EMR applications and eventually serve as the ultimate health information exchange.

Rather than having expensive hardware and software at your office, requiring expensive maintenance and upgrades the applications and data are hosted at facilities designed as large enterprise secure sites.

Security is no more an issue than that for any present applications, and in most cases, better. 

Many physicians are uneasy with patient databases off site, and concerned with HIPAA regulations in their own offices. The burden for insuring security will be placed squarely upon vendors.

The likelihood of cloud computer solutions increasing for business and healthcare is increased as large enterprise hardware vendors such as Dell acquire ASAP software, Everdream (provider of SaaS software solutions and remote-service management), Network Storage Co., Exanet, Ocarina Networks,Boom (SaaS), Apple, and many others have invested in building or acquiring large data centers.

Hewlett Packard purchased EDS (Ross Perot) to form HP Enterprise Services, which in addition to large data centers has much experience in healthcare solutions for health plans, government health, and life sciences.A leader in healthcare solutions

HP is the largest provider of healthcare information technology (IT) services in the world,encompassing the health plan, provider, life sciences, and government healthcare segments. Their solutions bring together unmatched experience, proven capabilities, domain expertise and industry knowledge, strong applications know-how, and practical innovation.

 

In 2009 Apple acquired property in Maiden, NC and began to build out a 500,000 square foot 1 billion dollar data center.

http://www.youtube.com/watch?v=hDXSSi1qStA

The cloud is the last to arrive in the healthcare space and EMR in particular. Several years ago vendors began to offer ASP solutions which are similar to but less efficient that true cloud platforms.

Now clear weather in the EMR space will be replaced by clouds.

Other business spaces already use cloud solutions for many functions in CRM, Inventory, Process Management,

The functions, also known as SaaS (Software as a Service), are in operation and offered by Amazon, Amazon Web Services (AWS), and at the end of 2009 the largest ten companies in SaaS were: Tera, Netsuite,IBM,Joyent, VMware, Google, and Rackspace. And the winner is …..Amazon !

In 2010 Enomaly, GoGrid, and AT&T, and Microsoft Azure have emerged from the young additions to the cloud.

Competition in the cloud space involves the diversity of applications as well as response times. No one wants to sit and wait for a screen refresh while a patient sits in your examining room, or the receptionist and billers twiddle their thumbs (at your expense) waiting.

The basic robust hardware/software infrastructure is already present.

Health Train Predicts that it will take five years for this technology to evolve and mature. The overwhelming advantage of this computing power is affordability of advanced algorithms and solution analysis for diagnosis and treatment. EMR will approach the medical record with artificial intelligence .s It is green technology markedly reducing requirements for cooling, and energy for end users,

The feds, insurers, and CMS are doing the health system, doctors, patients, and ultimately the tax paying public a great disservice with pushing for meaningful use, premature incentives with unrealistic time frames that will cost us all in the long run.

For those us who have implemented a system, so be it.  Wait five  years, at which time your system will be obsolete, and you will be faced with  a major upgrade expense………consider a switch to the cloud……And for the rest of us, hold off, wait and do not be precipitated investing into already dated technology.  IT advisory panels have recommended that CMS modify stages II and III definitions for meaningful use.

The eHealth Initiative recently sent a comment letter to the Office of the National Coordinator for Health IT, expressing concern about the proposed timelines for Stage 2 of the meaningful use program, Health Data Management reports.

Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs can qualify for incentive payments through Medicare and Medicaid.

The letter argues that the regulatory timeline included in the proposed criteria for Stage 2 provides "an inadequate amount of time for eligible hospitals to follow an implementation and testing schedule," adding, "A rushed process could potentially affect patient care."

The group did not explicitly ask for ONC to delay the start of Stage 2, but instead asked federal officials to "address the issue of inconsistent timelines" for regulations and the start of Stage 2

Additional Recommendations

In its comment letter, the eHealth Initiative also called for greater focus on health information exchange in Stage 2 of the meaningful use program. According to the group, the proposed Stage 2 requirements continue to focus on EHRs and do not give health care providers enough flexibility to use health data exchange to demonstrate meaningful use.

Read more: http://www.ihealthbeat.org/articles/2011/3/4/more-organizations-weigh-in-on-stage-2-timelines-objectives.aspx#ixzz1FgZLxzJE

In many cases users are already using cloud functionality, unknowingly with eRX prescribing via Surescripts either directly or via your EMR.

del.icio.us Tags: emr,cloud computing,SaaS,CMS,Health Train Express

International Health Day

The Health Train Express travels and becomes a global enterprise. 

No, I am not going to talk about the World Health Organzation (WHO). This post is going to recognize respected and interested international Visitors on Health Train Express. I recently installed ‘Feedjit’, a tracking tool of visitors to THTE  And here are where there are readers.

Amsterdam,Hyderabad,Moscow,Tordas,Pune,Maharashtra,Tarlac,Nairobi, Delhi,Bangaladore,Saskatoon,

Thanks for the visit !

del.icio.us Tags: international,world health,health train express

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