phenomenalplace

This week's post is not about a specific company's technology, but about a concept. My wife did something very cool for me for Christmas. Given that 2011 was filled with Hurricanes, Earthquakes, Tornados, Floods, and Fires around the world, she decided to create something that would make us more prepared for whatever the future may bring. She created a disaster pack for the front hall closet using a Black Diamond Speed 30 mountaineering pack as a "grab and go" answer to any disaster that strikes.   It contains 72 hours of food/water, basic medical supplies. a solar powered radio, tools that can be used to harvest wood/start a fire, and extra clothes. From the point disaster strikes to the point we're in a car with our supplies driving away could be under 60 seconds. Think about the time it would take to assemble food/water, clothing, and medical gear after disaster strikes - 15 minutes?  Half an hour? I highly recommend a "grab and go" pack as part of yo...

It's been two weeks since my wife said "I have cancer" to my daughter. It's been a week since we described our workup thus far on my blog. Reaction to our blog post was diverse, ranging from the HISTalk blog to the Boston Globe . It's a time of anxiety and unanswered questions.   The diagnosis and staging phase has been described as one of the two major tension points in  cancer.   The other is the time after remission, when the worry about recurrence is a constant burden.  One of our doctors recommended we keep a "family bottle" of anti-anxiety medication ready for those times when the stress exceeds our capacity to cope.   Cancer is truly a family disease and the emotional impact extends from the patient to family caregivers. Many friends and colleagues have offered prayers and support.   A few have lamented that care coordinated by a physician-husband at a Harvard-associated hospital in Boston lacks equity since every wife/mother/dau...

2011 was a year of change and tumult.   For a day by day look at the top stories of 2011, check out this impressive chart from the UK Guardian . It was a year in which the economy sputtered worldwide, the Arab Spring toppled several regimes, and unprecedented acts of nature (severe weather, earthquakes) caused billions in worldwide damage. What about the world of healthcare IT? Federal In 2011, Meaningful Use and Certification accelerated healthcare IT adoption and doubled implementation of EHRs throughout the country.    Every aspect of the industry was stressed along the way *Vendors were challenged to add the features necessary for certification resulting in some "haste makes waste" lack of usability and workflow integration.   GE admitted its faults and should be congratulated for its honesty, since many other vendors had the same problems but did not communicate them. *IT organizations created productivity miracles to meet meaningful use timefra...

As the year ends, I've spoken to many CIOs.   2011 was a hard year filled with Meaningful Use (including many upgrades to certified systems or self-certification),  5010 (the deadline for upgrading billing systems is January 1, 2012), accelerating compliance demands,  new security threats, rapidly evolving technologies, and unprecedented demand for new projects driven by the consumerization of IT . At the same time that CIOs and IT professionals are running marathons, they are being held accountable for events that are not directly under their control.   They are not being congratulated for the miracles they create every day, but are being criticized for not moving faster. What do I mean? One CIO received a negative audit report because new generations of viruses are no longer stopped by state of the art anti-virus software.   Interesting.  The CIO cannot control the virus authors, nor the effectiveness of anti-virus software.    No one in the ind...

In a previous post I described the capabilities of the Microsoft Kinect technology . I've written about sterilizing iPads and iPhones for use in the operating room and that does work, but there are challenges with subjecting electronics to sterilization. However, there's another cool option for examining medical records and digital images in the OR - a touch screen you do not touch.  Check out this gestural interface to EHRs and PACS systems that uses an Xbox and Kinect. Traverse pages, select tabs, and zoom into images using only body movements. The system, called TedCas, was recently named one of the top applications for Kinect . That's cool!

by Brian Klepper and David C. KibbeSix months ago, who could have imagined that a large percentage of rank-and-file Americans would support the Occupy Wall Street (OWS) against special interests’ rigging of the American dream? So why not go to the next step? Why not pointedly ask political candidates, “Will you take money from lobbyists?” and “If elected, what will you do to stop special interest

Cancer.  It's a word that creates fear and uncertainty.   Many of the doctors I know use the word "hate" whenever they discuss their feelings about cancer. Last Thursday, my wife Kathy was diagnosed with poorly differentiated breast cancer.    She is not facing this alone. We're approaching this as a team, as if together we have cancer.  She has been my best friend for 30 years.  I will do whatever it takes to ensure we have another 30 years together. She's has agreed that I can chronicle the process, the diagnostic tests, the therapeutic decisions, the life events, and the emotions we experience with the hope it will help other patients and families on their cancer treatment journey. Here's how it all started. On Monday, December 5, she felt a small lump under her left breast.   She has no family history, no risk factors, and no warning.   We scheduled a mammogram for December 12 and she brought me a DVD with the DICOM images a few minutes after ...

On December 19, CMS announced the selection of 32 Pioneer ACO organizations , five of which are Boston-based:  Beth Israel Deaconess, Mt. Auburn, Steward, Atrius, and Partners Healthcare. To participate in the shared savings model, we'll need to compute 33 different quality metrics and submit them via survey, claims or the group practice reporting web interface (GPRO). What are these metrics? 7 measure the Patient/Caregiver Experience based on survey 6 measure Care Coordination/ Patient Safety 6 based on claims or submissions to the GPRO web interface 8 measure Preventative Health based on submissions to the GPRO web interface 12 measure care to At Risk Population based on submissions to the GPRO web interface Here's a comprehensive list of what needs to be computed, how, and when . At Beth Israel Deaconess, we'll use our all-payer claims warehouse and quality data center.   My role as CIO has been to prepare the necessary analytics for panel and population health, as des...

The December HIT Standards Committee included a discussion of the work ahead for the next year based on the priorities we've heard from stakeholders.    We'll have 10 in person and 2 telephonic meetings in 2012.   Our topics by quarter will be as follows January-February-March 1.  Assuming that the Meaningful Use Stage 2 Standards and Certification Notice of Proposed Rulemaking will be published in early 2012, the HIT STandards Committee will need to review any comments submitted.   In the meantime, we'll continue work on testing criteria and will ensure any test scripts are piloted before they are finalized. 2. Quality Measurement standards As I've mentioned in other posts, there are three key elements of work needed to improve quality measure computation and submission.   First, quality measures need to be simplified so they are based on data elements that exist in EHRs and are captured during normal workflow.   Second there needs to be a simple mec...

BIDMC has two million square feet of wireless coverage using over a thousand 802.11n/a/g access points.   We operate two separate networks - a secure network for clinical applications and a guest network for visitors. The guest network is physically separate from the secure network and uses a commercial 14 megabit per second DSL line from Sprint for internet services, reducing BIDMC's responsibility for malware control and digital millennium copyright act violations.    Like any public, unrestricted network, the guest network offers the freedom to download malware, broadcast viruses, and use insecure applications. In a world of Netflix and YouTube,  compounded by bandwidth consumptive standards such as MPEG4, the demands on the guest network are infinite.    Can the hospital afford to provide free bandwidth to every visitor (inpatient, outpatient, families, students etc) when 80% of the traffic is streaming video? If we do provide infinite free bandwidth, w...

Many of my posts lately have described the challenge of securing and managing consumer devices brought from home. In the past, I've discussed the products from Good Technologies . I recently polled the CIOs of Massachusetts hospitals and found two other products that are gaining traction - Fixmo and MobileIron Fixmo creates a secured, encrypted container, the SafeZone, providing secure mobile messaging and data for businesses. Companies allow mobile devices into their own SafeZone and can restrict application and data access ensuring device integrity and compliance. A safe, sandboxed environment is created in which mobile devices can run and access network resources without compromising the internal network's safety. With SafeZone, employees can use all the features on their iPhones and Androids while a section of those devices is secure for sensitive company data. Data within SafeZone is certified FIPS 140-2 AES 256-bit encryption and encrypted within a company's infrast...

I've written about some of the perils of using consumer devices on hospital networks  . Now add to that risk, the distraction of mixing personal activities with patient treatment. Blogs are filling with debates about patient safety in a multitasking connected world . Even the New York Times has published an article about the possible negative consequences of mobile devices . In that context, AHRQ asked me to write a balanced commentary looking at the quality, safety, and efficiency pros and cons of using multitasking mobile devices for healthcare. I hope you enjoy it and draw your own conclusions about how these devices are best used in your hospital of professional office setting.

House Budget Chair Paul Ryan (R-WI) and Senator Ron Wyden (D-OR) have embraced a Medicare reform plan that in concept borrows heavily from one championed by former New Mexico Senator Pete Domenici and former Clinton budget chief Alice Rivlin.Specifically, Wyden and Ryan are proposing to alter the earlier Ryan Medicare plan by:Continuing to offer the traditional Medicare plan—Ryan would have

The stock market today was shocked, simply shocked, that the Super Committee didn’t come up with a debt deal.I don’t know why. Republicans can’t vote for more taxes unless they're willing to get “primaried” from the right and risk losing their seat. Ditto for Democrats who would face the same punishment from their base if they voted to change the sacred defined benefit entitlements without at

Republican presidential frontrunner Mitt Romney has pledged to end “Obamacare.” Upon taking office, he would immediately begin the process by granting the states waivers from having to implement it:“I’ll grant a waiver on Day One to get repeal started. On Day One, granting a waiver for all 50 states doesn’t stop it in its tracks entirely. That’s why I also say we have to repeal Obamacare, and I

Update: The New Wyden-Ryan Plan - Paul Ryan and Ron Wyden Blow the Medicare Reform Debate Wide Open! In a speech at the Hoover Institution today, Representative Paul Ryan (R-WI) argued again that his proposal to reform Medicare, and now his tax credit proposal for replacing the Democratic health care law for those under-age 65, would guarantee to citizens “options like the ones members of

The Health Leadership Council (HLC), a coalition of CEOs from many of the leading health care companies, has created a list of Medicare reform recommendations for the Super Committee tasked with finding at least $1.2 trillion in budget savings.As we begin the national debate over what to do about Medicare's unsustainable costs, I will suggest that the HLC proposal gives us one, of what will have

It’s back to work in Washington, DC and all the attention is now on the Super Committee and their goal of cutting spending by at least $1.2 trillion over ten years.If the committee fails to come up with a plan that passes the Congress, there would be $1.2 trillion in automatic cuts. The health care special interests have reason to hope they will fail—the fallback cuts would only impact Medicare

A recent New York Times article - "A Dashboard for Your Body" - led me to nose around the web to learn more about developments in what is often called "self-tracking." It's a fascinating area that is likely to change medical practice, the patient-physician relationship, and even the ways in which we think about ourselves. Home monitoring devices are already letting clinicians - and perhaps more importantly, family members - keep a virtual eye on the frail elderly and homebound people with chronic illnesses. When our dispersed lives keep family members and close friends from keeping a literal eye on a person in need, devices with internet connectivity allow tracking of vital signs, blood sugar, movement in the living space, eating, and more. These capacities would have been useful to me, an only child, and my father, in his 80s and legally blind from macular degeneration, during the years he lived in Florida, a thousand miles away. The telephone, and the front d...

by Brian Klepper and David KibbeOne of American politics’ most disingenuous conceits is that health care must cost what we currently pay. Another is that the only way to make it cost less is to deny care. It has been in industry executives’ financial interests to perpetuate these myths, but most will acknowledge privately that the way we value and pay for medical services is a deep root of

The road to hell is paved with good intentions. The FDA has reaffirmed the truth of this aphorism with its policy about Colchicine. Here's the story: I recently spoke with a friend who has a family member suffering from Familial Mediterranean Fever (FMF), an auto-inflammatory disorder, most commonly seen in eastern Mediterranean populations. The condition is characterized by recurrent painful inflammation of the abdomen, chest and joints, accompanied by fever. FMF is associated with mutation of a gene on chromosome 16 involved with regulating Pyrin, a protein that is part of the inflammatory response. There is no specific test for the disease. Diagnosis is made on the basis of symptoms, family history, and ruling out other conditions. Since the 1960s, Colchicine, a plant extract first used for treatment of gout two thousand years ago, has been used for treating FMF. As an ancient treatment widely used prior to formation of the FDA, Colchicine did not require FDA approval as a new ...

The debt deal is finally done. But it really isn’t an agreement on what cuts will be made, just the process that will be used to make them.The real work is left to the Congressional appropriators for the first $917 billion and for a super-committee of Congress for the second $1.2 trillion to $1.5 trillion in ten-year cuts.That second tranche is where health care will make its contribution. The

A recent conversation with a friend about his father's nursing home experience taught an important lesson about nursing home ethics. Here's the story: His father suffered from severe Alzheimer's and required full time supervision. A local nursing home that had a mediocre reputation some years back was said to have improved, and the family placed his father there. The nursing home was in another part of the country, so my friend could visit only intermittently. On each visit he was impressed with the attentive, loving care the residents received. His father lived in the nursing home for a few years before his death. When my friend made a final visit to collect his father's belongings and to thank the staff, he was invited to look at the nursing record. The final entry said it all with regard to the ethical ethos of the home: May God grant peace to his gentle soul! I teared up when he told me this and teared up again as I wrote it. My friend spoke with the administrator w...

On this blog a month ago, I said the politicians were starting to scare me with the apparent eagerness of some to actually take the government to default to make a political point.For weeks we have heard political leaders on both sides tell us there would be no default.But the two sides have so backed themselves into opposite corners that they have left no opportunity to meet in the middle.

If you're interested in Vermont's plan for a single payer system, you'll want to look at an article in this week's New England Journal of Medicine. According to Anya Rader Wallack, Ph.D., special assistant for health reform to Governor Shumlin, the Vermont program will include "a global budget for health care expenditures, guaranteed coverage that is not linked to employment, and a single system of provider payments and administrative rules." The health system will be overseen by a new public entity - the Green Mountain Care Board. Here's how Dr. Wallack describes the powers of the board: The board can wield traditional tools such as fee-for-service rate setting, controls on the acquisition of technology, and reviews of both health insurers’ rates and hospitals’ budgets. However, the law also provides explicit direction to the board to create a global budget for health care spending and develop new payment models that create incentives for providers to st...

I'm in Vermont, telecommuting and enjoying the Green Mountains while my wife teaches at the Bread Loaf School of English , a Middlebury College program in which students, mainly K-12 teachers, can get a Masters degree in the course of five summers. Students and faculty have meals in a building that served as a summer Inn a century ago. Last night at dinner two faculty members I was sitting with began to talk about how many Weight Watcher "points" the different foods had. They graciously allowed me to grill them on their experience with weight management. Here's what I learned: Neither had succeeded in maintaining weight loss on his own. While they did not care for the meetings associated with the Weight Watcher program, both found the weekly "check in" helpful. I probed. Did they have an extended conversation with the person who weighed them? No. Was it always the same person? Yes, usually. But they did not appear to find the relationship itself important. I...

Last week I read a fascinating book by Charles Bosk - " What Would You Do? Juggling Bioethics and Ethnography ." Bosk's first book - " Forgive and Remember: managing medical failure " - a brilliant field study of surgical training, made him famous when the first edition was published in 1979. I can't evaluate his skills as an ethnographic field worker, but he's a terrific writer. In a chapter on "Irony, Ethnography, and Informed Consent," Bosk reports the intense distress a genetic counselor experienced on seeing how he'd written about her and reflects on the nature of informed consent in ethnographic research. The ethnographer is not doing an experiment for which the risks and benefits can (and should) be described clearly to those who are being asked to participate. But he describes how ethnography characteristically seeks to "debunk" (his word) conventional social constructions, and he comments that ethnographers often write wi...

The Chronicle of Higher Education recently reported that University of Pennsylvania psychiatrist Jay Amsterdam has accused his department chair and four colleagues of publishing an article that was (a) ghost written by a contractor for GlaxoSmithKline and (b) biased in favor of the GSK antidepressant Paxil. Amsterdam complained that the article "was biased in its conclusions, made unsubstantiated efficacy claims, and downplayed the adverse event profile of Paxil." He contends that "data from his study was effectively stolen from him, manipulated, and used in a ghostwritten article" designed "to advance a marketing scheme by GlaxoSmithKline to increase sales of Paxil." I'm writing this post without any insider knowledge about what's going on in the Department of Psychiatry at the University of Pennsylvania. Dr. Amsterdam's faculty profile, last updated 16 months ago, shows him to be a specialist in treating depression. The Chronicle post report...

Click to Enlarge   Source  The current issue of Annals of Internal Medicine  has a great article on individualization of mammography recommendations -more on that in the next few days. There is another article demonstrating that an inexpensive ultrasound machine that fits in a pocket is almost as good at certain measurements of heart anatomy as a conventional ultrasound machine - which would frequently generate a health care bill of $1500. When I saw the abstract, I thought that Clay Christensen's predictions about disruptive innovation in health care were finally coming to pass - and we were going to use technology that was a little bit inferior to existing technology, but perfectly adequate for many indications - and save big bucks. This could be the cardiac imaging equivalent of the personal computer going up against mainframe computers! Alas, this was not to be. The authors position the pocket echocardiograph to replace not the expensive conventional echocardiogram,...

Here's the opening of a fascinating article in today's New York Times: Doctors save lives, but they can sometimes be insufferable know-it-alls who bully nurses and do not listen to patients. Medical schools have traditionally done little to screen out such flawed applicants or to train them to behave better, but that is changing. At Virginia Tech Carilion, the nation’s newest medical school, administrators decided against relying solely on grades, test scores and hour long interviews to determine who got in. Instead, the school invited candidates to the admissions equivalent of speed-dating: nine brief interviews that forced candidates to show they had the social skills to navigate a health care system in which good communication has become critical. I'm embarrassed to acknowledge that although I've done a lot of interviewing, I'd never heard about the technique Virginia Tech Carilion is using - multiple mini interviews (MMI). Applicants are seen at multiple interv...

Today’s Managing Health Care Costs Indicator is 89,824 Click to enlarge.   Source  Oregon  realized it had resources to add about 10,000 beneficiaries to the Medicaid roles in 2008, and decided to hold a lottery to determine who would be awarded this Medicaid insurance.    89,824 Oregonians were eligible, 29.664 were randomized to be able to apply for Medicaid, and about 1/3 actually qualified.  (Reasons for not qualifying included not completing the paperwork or having income that was too high.). Researchers at Harvard used this natural experiment to see what the impact of winning this Medicaid lottery really meant.   This natural experiment is ideal to determine the effect of gaining potential Medicaid eligibility – because the 30,000 who won the lottery (experimental group)  were randomly chosen, making it unlikely that they were significantly different than those who did not win the lottery (control group). This i...

Judge Jeffrey Sutton's finding on the health insurance mandate in the U.S. Court of Appeals (Sixth Circuit) gives hope that the right wing is not totally bonkers. Before readers flame me for questioning Tea Party theology, here's what David Brooks, the conservative New York Times columnist, wrote about Republicans on Tuesday with regard to the debt ceiling "debate": ...the Republican Party may no longer be a normal party. Over the past few years, it has been infected by a faction that is more of a psychological protest than a practical, governing alternative. The members of this movement do not accept the logic of compromise, no matter how sweet the terms. If you ask them to raise taxes by an inch in order to cut government by a foot, they will say no. If you ask them to raise taxes by an inch to cut government by a yard, they will still say no. The members of this movement do not accept the legitimacy of scholars and intellectual authorities. A thousand impartial e...

Today’s Managing Health Care Costs Indicator is $330 billion The Centers for Medicare and Medicaid Services issued its draft 2012 payment rules yesterday. The  payment rules give modest increases to ambulatory facility fees, tie ambulatory surgery fees to quality reporting, and make some much-needed changes in imaging reimbursement.   The headline is that these draft payment rules cut physician fees by almost a third, as required by the sustainable growth rate formula.   This is the automatic trigger that has been overridden by Congress every year (or more) since 2002.   Just about no one thinks this is a good idea.  Physician payment increases in Medicare have been substantially less than those offered by other payers, and in some communities it's hard to find a physician taking new Medicare patients.   Click to Enlarge  Ginsburg,  New England Journal 12/10  The cost of physician services keeps on going up, and no efforts to lower utili...