August 20,2014

12:34

A recent article reported the results of a study showing wide variation in the cost of lab testing in California hospitals (see: Charges for 10 common blood tests at California hospitals). This is not news to anyone involved in the management of clinical laboratories. Below is an excerpt from the article:

Researchers studied charges for a variety of tests at 160 to 180 California hospitals in 2011 and found a huge variation in prices. The average charge for a basic metabolic panel, which measures sodium, potassium and glucose levels, among other indicators, was $214. But hospitals charged from $35 to $7,303, depending on the facility....The biggest range involved charges for a lipid panel, a test that measures cholesterol and triglycerides, a type of fat (lipid), in the blood. The average charge was $220, but costs ranged from a minimum of $10 to a maximum of $10,169....The smallest range in charges was for a blood test that checks an individual’s red and white blood cells. It cost $37 to $278....Most consumers with health insurance won't pay those prices; most often, their health plans have negotiated a lower price with the hospital or provider. But patients without insurance face the full brunt of the charges, especially if they don’t qualify for a hospital’s charity care discounts....In general, county hospitals and teaching hospitals had lower prices than non-teaching hospitals, not-for-profit and for-profit hospitals, she said.....The majority of hospitals were not-for-profit, urban, non-teaching hospitals....One factor that researchers weren’t able to measure was a hospital’s investment in higher quality facilities or supplementary services.....The bottom line, according to the study, is that hospitals recoup losses in other areas from third party payers to cover overall costs. “This often results in some services subsidizing others, with their charge increases generally unrelated to their value,” the study concluded.

I have blogged about hospital costs and charges a number of times. One of the most relevant notes dates back to December, 2008 (see: Why the Prices Charged by Hospital for Inpatient Care Are Irrelevant). The basic point I made then was that hospital charges are not worthy of analysis because they are have no relevance to the cost of services. In short, a charge of $7,303 for a basic metabolic panel is set by the hospital and has nothing to do with the cost of the test. Although articles such as the one above are shocking, they simply emphasize the extent to which hospital pricing systems are out of whack.

The process by which hospitals get reimbursed for their services is by tallying up their costs for patients in a disease group and then negotiating with health insurance providers for reimbursement for that cost plus some profit margin. Certain activities like a stay in an intensive care unit are labor intensive and the charge for the service is far less than its true cost. Lab testing, on the other hand, is highly automated so the charges are far more than their cost. The last couple of sentences in the excerpt above explain all of this: [Hospital billing practices result] in some services subsidizing others with their charge increases generally unrelated to their value.  

So what is the value of articles such as the one quoted above? The key take-home lesson is that hospital billing needs reform. However, all of the key players like hospitals and health insurance companies are used to the system so that chance of reform is probably slim. The only people who get mauled by hospital billing is the uninsured and those with high co-pay policies. A number of hospitals, particularly in California, offer steep discounts to the uninsured but these discounts need to be negotiated at the time of admission (see: Hospitals in California Offer Steep Discounts to Uninsured PatientsTexas Web Site Lets Healthcare Consumers Shop Around).

9:16

The following is a guest blog post by Carrie Yasemin Paykoc, Senior Instructional Designer / Research Analyst at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
workout
Investing in an electronic health record (EHR) is largely based on the decision to improve patient safety, align with clinical guidelines, enhance revenue cycle times, and capture government-based incentives. But without a proper EHR adoption plan in place, healthcare providers risk never optimizing their investment and achieving their intended goals.

Once an EHR is implemented, healthcare organizations must continue striving toward their goals to optimize their systems. Improving workflows, establishing best practices and increasing overall proficiency of end-users in this application are all components of optimization. Healthcare organizations that are able to maintain this level of focus will see improved clinical and financial outcomes.

This process isn’t easy and requires a commitment to the initial performance metrics that drove the healthcare organization to purchase the new system. Today, nearly half of all healthcare organizations use an EHR, but many struggle to ensure it provides clinical value across the organization. They carefully select and implement systems but fail to make the tool work as originally envisioned. Just because they bought a new EHR doesn’t mean it is serving their patients, providers, or bottom line.

A parallel comparison can be made with buying a high-end, a mobile exercise device to track aerobic and anaerobic steps. Individuals seeking a healthier lifestyle invest in these devices, hoping it will help them achieve their personal health goals. After making the initial investment and adapting daily habits to wear the device, one can begin to adopt the technology to achieve improved health goals. But realizing these goals takes work and commitment. If performance is not monitored, results can plateau and, in some cases, regress. This could result in a growing waist line for the person trying to lose weight, an ironic and unfortunate twist. For healthcare organizations, their growing waistline is unhealthy organizational performance, visible through increases in adverse drug events, recurrent admissions, revenue cycle times and government penalties, all symptoms of goal misalignment. The more healthcare organizations look away from their initial performance goals and utilize EHRs for data storage only, the more noticeable the symptoms become. Both individuals and healthcare organizations can benefit from the process of system optimization to make the tool work for the betterment of the individual or organization.

Extensive research has been conducted by The Breakaway Group (TBG), A Xerox Company, to identify elements that lead to optimization. TBG reports the key adoption elements exhibited by healthcare organizations that optimize their EHRs:

Engaged and Clinically Focused Leadership
Healthcare organizations must demonstrate engaged and clinically focused leadership. Clinical leaders must align their EHR by refining workflows, templates, utilization, and reporting to meet their organizations’ clinical and financial goals. The Chief Medical Information Officer (CMIO) is well suited for this venture.

Targeted Education and Communication
Healthcare organizations must provide targeted education and communication.  When system upgrades are released, organizations must effectively and efficiently educate end users to alleviate reductions in proficiency and productivity.

Comprehensive Metrics
Healthcare organizations must be able to use EHR data.  Organizations must move past the superficial use of an EHR and begin to analyze what is entered. The EHR is of little value, if the data is neither clinically valuable nor used.

Sustained Planning and Focus
Healthcare organizations must sustain planning and focus. Change occurs frequently in healthcare, so system optimization requires preparation, adjustment and real-time communication.

With these adoption elements, healthcare organizations can make their technology work as originally intended—to improve patient and financial outcomes. To overcome the EHR implementation plateau, they must focus on their original performance goals to truly optimize health information technology systems. This process isn’t easy. It requires endurance, but the payoff is worth it. It’s time to “Breakaway” from the status quo and work IT– by optimizing use of HIT systems!

Carrie Yasemin Paykoc
Xerox is a sponsor of the Breakaway Thinking series of blog posts.

6:00
Image: CC BY 2.0 Robert Scoble

Image: CC BY 2.0 Robert Scoble

The first time I saw someone wearing Google Glass was at HIMSS14 in Orlando. My initial reaction: that guy looks like a geek. Not that I have anything against the geek look but I couldn’t imagine myself ever wearing Glass goggles while walking about in public. I’ve progressed a bit and no longer giggle when I see someone wearing a pair, yet I wasn’t impressed by the Glass-wearing guy (definitely a Glasshole) that I recently noticed driving in a car next to me.

On the other hand, plenty of folks in the health IT world were quite impressed with Dr. Rafael Grossmann, the first physician to record a surgery wearing Google Glass. Since that landmark event about a year ago, a small number of companies have popped up offering healthcare solutions that leverage Google Glass. It’s perhaps too early to tell which ones will still be around next year but here’s a short list (in alpha-order) of some that are making in-roads:

APX Labs – APX has built a robust, horizontal data-integration platform optimized for smart glasses. They promote their solution for a variety of industries in addition to healthcare, but the clinical applications focus on telemedicine, first responders, nurse and clinical EMR interfaces, vitals monitoring, administrative visibility, and medical education. From what I can tell, they either don’t have any healthcare customers yet, or, they are still opting to fly well under the radar.

Augmedix – Augmedix claims to be the world’s first Google Glass start-up and their application focuses on improving the clinical documentation process. In January the company conducted a pilot with the California-based Dignity Health, who provided three family physicians with Google Glass and Augmedix’s physician documentation app. After four months the doctors reported a drop in the amount of time spent documenting from 33 percent of their day to nine percent and an increase in time spent directly engaging with patients from 35 to 70 percent of their day. Compared to some other vendors, the Augmedix application appears to be more narrowly focused.

ContextSurgery – The Context-aware software is geared to the operating room and includes a Surgical Dashboard that pushes relevant patient information to Glass-wearing providers. The HIPAA-compliant application also supports video-sharing. I assume that the company is still in the development stage as they are looking for additional betas to test their product.

CrowdOptic – ProTransport-1 recently announced it will deploy the CrowdOptic Google Glass broadcasting solution in its ambulances and mobile medical machines to broadcast real-time video of patients in transport.  UC San Francisco is also testing CrowdOptic software to enhance physician training through the use of live video streaming from Glass devices.

Pristine – Pristine offers the EyeSight product as a HIPAA-compliant, first-person audio/video streaming solution optimized for Google Glass. Currently their platform is in use at several facilities, including UC Irvine Medical School and Houston Methodist Hospital (to allow physicians to broadcast procedures to students or for continuing education purposes) and Rhode Island Hospital (for remote dermatology consults). The Chicago-based MedEx Ambulance service also recently acquired Pristine’s technology to allow Glass-wearing paramedics to transmit live video and audio from an ambulance to an ER doctor.

Remedy – Remedy has launched a pilot study with three Harvard hospitals in which Glass-wearing PAs will connect with doctors (usually at night), allowing the supervising physicians to “see” the patients. Remedy is targeting its application for use by residents, medical students, general practitioners, nurses, and PAs to extend the reach of specialists.

Wearable Intelligence – Physicians at Beth Israel Deaconess Medical Center are using devices from WI as a means of gaining hands free access to patient charts. The company also promotes a procedural checklist application and telehealth and video recording options for healthcare. In addition to the high-profile BIDMC, the multi-national oil services firm Schlumberger also uses WI’s Glass applications.

I’m impressed by the number of big-name health systems that are giving Google Glass a test drive. It’s also interesting to note the diversity of applications, from telehealth, education, remote consults, and EMR access. By the time HIMSS15 rolls around next April I am sure we’ll have a clearer idea of which vendors have figured out the formula for success.

And regardless how hot the market gets, I doubt I’ll be Glass-adorn any time soon.

Categories: News and Views , All
6:00
CernerCerner Corporation (Nasdaq: CERN) and Siemens AG have signed a definitive agreement for Cerner to acquire the assets of Siemens' health information technology business unit, Siemens Health Services, for $1.3 billion in cash. By combining investments in R&D, knowledgeable resources, and complementary client bases, the acquisition creates scale for future innovation.
3:00
CarestreamThe Mid-Yorkshire Hospitals NHS Trust, consisting of Pinderfields, Pontefract and Dewsbury and District Hospitals, has installed six CARESTREAM DRX-Revolution Mobile X-Ray Systems to help provide rapid access to high-resolution X-ray images for improved patient care.
2:31
Spotted this a few days ago.Here is the full page:Our Work eHealth Reference Platform The eHealth Reference Platform is a clinically validated technical simulator for eHealth, with technical services and sample code supporting demonstration, training and development testing.There are no articles in this category. If subcategories display on this page, they may contain articles. Link is here:http://www.nehta.gov.au/our-work/148-ehealth-reference-platformThis is really one of the funniest pages I have seen in a good while and just typifies the old and failed NEHTA mindset. User understanding, not technology, is what is needed to e-Health to ever work.There is a prize available for the first person to explain just how you clinically validate a technical e-Health simulator.It is this sort of focus and direction of effort by NEHTA that confirms NEHTA has its priorities all wrong.Just why exactly does a content-less page like this exist?The sooner they are ‘dissolved’  and...

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All

August 19,2014

22:20
Because one of our sites has decided to replace some generations-old equipment, I had the joy of going on two site visits over the past couple of weeks. Both were sponsored by BIG NAMES, and both fell rather short. Which prompts me to examine the entire concept of the site visit.

In brief, the site needs two quite different pieces of equipment, both sold by the BIG VENDORS in question. Both teams got only half of it right, one showing us the first, and one showing us the second. Both seemed to be a little oblivious to the fact that we needed one of each. My recommendation at this point is to buy one machine from one vendor and the other from the other. I doubt that will happen.

So what went wrong? I'm not totally sure, but I think it probably comes down to someone not listening. I think we made our needs pretty clear, but...

Site visits can be fun, at least they were in the old days. I've been on what might have been one of the more expensive equipment junkets in the history of imaging. We had two Elscint CT's at the time, and the company wanted us to consider their MRI's. Our trip started at Elscint HQ in Haifa, Israel, and then took us to Kiel, Germany to see the only prototypes in existence of the machines we sought. The machines were actually quite impressive. Elscint had created one of the first high-field scanners, a 2T device, as well as a dual-gradient machine. There was just one little catch. The week before we left for the trip, Elscint was SOLD! GE purchased the nuclear medicine and MRI divisions, and Picker (later Philips) snagged the CT business. So GE ate the bill for me and my partner to look at scanners that were never manufactured! We did have a good time, though.

What is the point of a site visit? To see the machine? Here's a little secret: Most every scanner is a big box with a hole in it. Some have prettier cowling than others, some have a water-chiller in the corner, which looks rather like a fridge. Some have really nice LCD displays over the gantry. Whoopie. More importantly, one gets the chance to talk to the users, technologists, physicians, whomever. Usually, the salesmen have the tact to disappear for a moment so the bad stuff can be discussed as well as the good. (Bad stuff does come out..on our Fuji PACS site visit years ago, the PACS admin said, "Fuji support isn't so good and we have to maintain the system ourselves." Which was the end of Fuji.)

Of course, the most important part is the obligatory meal at vendor expense. But the days of picking the most expensive wine on the list are gone, and frankly I never felt terribly comfortable spending the vendors' money on frivolity anyway. Not that a fancy meal or trip can or should influence my choice, but the optics are what they are.

Ultimately, I think the days of the site-visit are numbered.

My friend Mike Cannavo, once again the One and Only PACSMan, ghost-wrote this paragraph for my RSNA Christmas Carol fantasy:
“Isn’t it obvious?” (the PACSMan) asked. “Here’s the deal. No one knows where healthcare is going, so we’re all going to start enjoying Thanksgiving again for the first time in 75 years. Instead of freezing our asses off, we’ll do an interactive virtual conference with scheduled demos and everything. No muss, no fuss, and no ‘free’ meals. As a bonus, system prices will drop 30% because vendors won’t have to pay for RSNA. It’s sheer brilliance, I tell ya!"
Mike was referring to the vendor extravaganza at RSNA, but I think this applies to site-visits as well. There is simply no need to haul people across the countryside (or country, for that matter) to see the scanner. They all look pretty much the same, and decisions are not made on the basis of their appearance. (Bore size and other specs are important, but that's all in the specs.)

Conversations with the important people can be choreographed by phone with little difficulty. And images, the most important piece of my puzzle, can be sent, hopefully in a form that will easily load on the customers' PACS. (Yes, that can be a problem.)

Hey, I like a paid day off as much as anyone else, but I'm getting too old to drag my carcass around the neighborhood and indeed the country to spend 5 minutes in the presence of the Holey Box and its keepers . Let's save a few thousands (or tens of thousands) of dollars and try it my way.

I've probably just made myself a target for those who like getting wined and dined and taken to various exotic places like we just were, but time change, boys. Go spend the time with your family instead. That goes for the vendors, too.
14:37

Excuse a moment of somewhat personal commentary, but this story in the New York Times has been making the rounds. Basically, the boards full of smiling babies in a doctor’s office are considered a privacy violation. Here’s an excerpt from the article:

Under the law, the Health Insurance Portability and Accountability Act, baby photos are a type of protected health information, no less than a medical chart, birth date or Social Security number, according to the Department of Health and Human Services. Even if a parent sends in the photo, it is considered private unless the parent also sends written authorization for its posting, which almost no one does.

When I read stories like this, I ask myself “Have we lost all common sense? Can’t we be human?” I get how privacy is important. I’ve written this blog for 9 years and so I know the consequences of HIPAA breaches. Although, I think Dr. Moritz covers my view really well:

“I think we have to have some common sense with this HIPAA business,” Dr. Moritz continued. “To leave medical records open to the public, to throw lab results in the garbage without shredding them, that makes sense” to prohibit. “But if somebody wants to post a picture of something that’s been going on for a millennium and is a tradition, it seems strange to me not to do that,” he said.

I know there are ways to comply with the law and preserve the baby board. Have the parents sign a release form when they drop off the picture. I think you could also add this note in your HIPAA notice that the patient signs before their first visit. However, I think this is missing the point. Isn’t it common sense that someone who sends a picture of their baby to the office isn’t afraid of having that picture shared?

Certainly this change is not life or death stuff. Although, I think the baby boards did provide some humanity to an otherwise sterile office. However, I hate the trend of where this leads. In far too many things we can’t be human anymore. Common sense is missing in so many areas of life and instead of giving people the benefit of the doubt we’re too easy to condemn people who had no ill intent.

I realize there are bad people out there that do bad things. However, they’re the minority and its sad when the minority is able to have such an impact on the majority.

10:05
Dalai's note: This piece is reprinted from today's American Thinker. It is one of the most eloquent, heartfelt, and most importantly, ACCURATE renditions of the Mideast situation today. It is a long essay, but well worth your time. Know the history. Know the TRUTH.

Speaking Truth to Crap


By Dan Gordon

I've been home from participating in Operation Protective Edge for about a week. I am in uniform no more, though I still wear my dog tags in solidarity with my brothers in arms, who, like all citizens of Israel, await the outcome of cease-fire talks in Cairo. Because we never wanted this war. It was forced upon us by Hamas. The current cease-fire is set to expire Monday at Midnight Israel time. Hamas has repeatedly rejected and/or violated each past cease-fire, so no one knows what will happen with this one.

I admit to being a bit cranky.

I don't think it's PTSD, though I've been to too many funerals, had a few too many close calls with rockets and mortars, had people with whom I'd celebrated the night before be killed the next day, seen chunks of the skull of a sixteen year old blown off by shrapnel from a mortar round I successfully dodged, only through luck and the grace of a loving G-d, who, I choose to believe, still has some use for me on the planet.

The song "Fire and Rain" is playing on the local oldies station and I think to myself, " Oh James, you Sweet Hippie Child, you haven't seen anything..."

You haven't been in a shelter during a rocket attack trying to comfort a little girl with nothing but the BS of an adult trying to comfort a child in a rocket attack, who knows better. You haven't seen people race for cover knowing they have only seven seconds before risking being blown apart. You haven't met people who've had to lock themselves in a so called safe room, while only a few hundred meters away a dozen terrorists, armed with anti tank missiles that could incinerate their home, machine guns, grenades, thousands of rounds of ammunition and hand cuffs, with which to take them prisoner and drag them through terrorist tunnels, into underground cells, are on the prowl, and they, this sweet family in a locked room, know that they are their targets. They will live or die in the next hour, depending upon the skill and bravery of eighteen and nineteen year old boys and girls, who are willing to lay down their lives, not to promulgate any occupation, nor subjugate another people, but to protect their homes and families, and on this particular day, some of those kids will do just that. They will lay down their lives to protect this family and others like them. The terrorists' secret "Divine Victory Plan" to kill, maim and take hostage, Israeli men women and children will be foiled and there will be new funerals of nineteen year olds who've given their lives to save the lives of that family huddled together behind a locked door in their home. And you think you've seen Fire and Rain, James?

Since I'm back I've become appalled by the lack of journalistic integrity I've seen in some coverage, and the sheer ignorance in the coverage of others.

I like listening to NPR on weekends. They have a comedy game show called "Wait, Wait Don't Tell Me." I'm driving from a friend's house and searching for it on the radio and an NPR news cast comes on. It's about Gaza, so reflexively, like all Israelis, I turn the sound up. Are we at war? Are rockets falling again? The reporter comes on. She has well modulated, upper crust British Public School pronunciation, as she describes the plight of Palestinian Fisherman in Gaza who now have a five hundred meter limit placed on their fishing activities by the Israeli Navy in the wake of the recent war. She describes it as if it is some cold hearted, at the very least, collective punishment of innocent Gazan Fisherman.

I mean how cruel can these Zionist oppressors of the downtrodden Gazan fishermen be?

We're talking fishermen here!

Peter was a Fisherman. Jesus preached on the shores of the Sea of Galilee...to Fishermen! Just like these poor Palestinian Fishermen whom the Israelis cruelly limit to fishing only five hundred meters from shore!

Nazis!

I can almost see a new site to match "Jesus at the Checkpoint," which tries to say if Jesus of Nazereth were alive today he would be a poor Palestinian, harassed by Roman-like, Jewish, Nazi soldiers at checkpoints in the West Bank. Jesus would be, were he alive today, separated from his neighbors by "The Apartheid Wall"!

Never mind that the checkpoints were a response to, and preventative measure against, the suicide bombers who claimed a thousand Israeli lives, who blew up women and children in pizza parlors and Passover Seders.

As for the so-called " Apartheid Wall," it is a security fence, only three percent of which is a thirty foot high wall. And why is there even three percent which is a thirty foot high wall? Because for years Palestinian terrorists from Kalkiliya and Tul Karem would shoot at cars on the Trans-Israel highway and kill Israelis. And by the way, since the barrier has been there, it's stopped almost a hundred percent of the suicide attacks. Period.

It's not Apartheid you bozo! It's self-preservation!

Twenty percent of Israel's population are Arabs, many of whom define themselves as Palestinian. They sit on our Supreme Court, which recently sent a former Israeli president and a former Israeli Prime Minister to Jail. They study and teach in our universities, serve in our military, are doctors and nurses in our hospitals, and enjoy the protection of the least corrupt, most liberal judiciary in the entire Middle East. Indeed no Arab country affords them the rights they have as citizens of Israel. Does that sound like Apartheid to you? I'll tell you what sounds like Apartheid. It is the fact that virtually every Palestinian leader has said that not one Jew will remain in a Palestinian state once it is created. In other words Judenrein. Jew-Free. Hitler's wet dream

But I digress.

Pardon the rant. I said I was cranky. Back to the poor Gazan fishermen who can't fish beyond a five hundred meter limit imposed by the Israeli Navy during the current war. What this Brit twit of an Oxbridge reporter fails to mention is that Hamas terrorists attempted to stage a water-borne terrorist attack on Zikkim beach near the Israeli city of Ashkelon. Happily, they were engaged and killed by some more 19-year-old Israeli kids willing to lay down their lives to protect the Israeli civilian farmers at Kibbutz Zikkim, where the terrorists were headed. That's why there's a five hundred meter restriction! Because Hamas terrorists, posing as poor Gazan fisherman, indeed, tried to carry out a terrorist attack against our civilians. Gazan fisherman are paying the price for Hamas terrorist attacks on Israeli civilians. But the Oxbridge modulated tones never mention that. They just sadly intone her name, and solemnly bear witness to yet another Israeli act of tyranny.

Gimme a break!

Do your homework you twit. Keep your prejudice, if you like, in the melodrama you wrote in your head before you ever even got there, but provide at least a little bit of context. Whattaya say?

All of which brings me to Jon Voight.

Mr. Voight recently penned an open letter to Javier Bardem and his equally talented wife, Penelope Cruz, for signing an open letter condemning Israel as a war criminal without once mentioning the name, let alone the deeds of Hamas. Mr. Voight took them to task and recounted Israel's history in a workman-like fashion, hoping to educate them, and his readers, regarding the facts leading up to the current conflict.

Mr. Voight has thus, recently been taken to task himself, by a member of Academia who has chosen to identify with the downtrodden, put-upon, maligned and much misunderstood freedom fighters of Hamas.

He has done so by taking his stand against the capitalist, pig, oppressors of the Palestinian masses, namely the dreaded Zionists.

He flaunts his academic credentials to poor Mr. Voight, a mere actor, and present the true facts and myths surrounding Israel, even going so far as to cite like-minded Jewish and Israeli academics, in order to enlighten the aforementioned, and hopelessly naive Mr. Voight. He, after all, has written and edited books specializing on (his grammar, not mine) the history and contemporary realities of Israel, Zionism and Palestine. The conclusion which the professor has drawn is that the United States and Israel are to blame "for the suffering Israel has inflicted on the Palestinian people." And to ice that academic cake, and bolster his argument to irrefutable heights, which, no mere actor could ever hope to scale, he quotes that leading expert on all things Middle Eastern, none other than John Leibowitz!

Oh...what's the matter ? You never heard of John Leibowitz?

That's because this particular proud Jewish comic, unlike guys named Seinfeld, Sandler, and Stiller, felt he couldn't make it merely on his talent. I mean, who ever heard of a Jewish Comedian? So he Anglicized himself into becoming a homey of the Oxbridge Patron Saint of Palestinian Fisherman, and thus, was born again as, Jon Stewart.

I like Jon Stewart.

I think Jon Stewart's a funny guy.

I think he's so funny, in fact, he could even have made it even if his name was Leibowitz.

But I'd no more depend on his analysis of the current conflict in the Middle East, than I would consult with Dr. Pepper about a medical condition. Dr. Pepper's a heck of a soft drink. But by Doctors, he's no doctor.

So this is not an open letter to this bozo of new left chic Academia. But it is a refutation of the same talking points raised by his fellow travelers seeking to delegitimize Israel's very right to exist as the sovereign nation state of the Jewish people. First of all, what you have to understand is, the very notion of a sovereign Jewish state, within any borders, is anathema to this crowd. They live in an enlightened, post-nationalistic mindset, where the only people in the Middle East entitled to be nationalists, in fact, are those who wish to establish, not a nation, but a Caliphate.

Regarding the birth of Israel in 1948, Mr. Voight rightly cites it having come about as a result of Israel's acceptance of the 1947 UN plan to partition Palestine into two states, one Jewish and one Arab. The Arab League and the Palestinians, represented by their revered leader Haj Amin Al Husseini, rejected the partition plan and the establishment of any Jewish State within any borders, and as Mr. Voight pointed out, Israel was subsequently "attacked by five surrounding Arab countries committed to driving them into the sea,"

The professor counters that poor Mr. Voight has been taken in by a Zionist myth. "This is a distortion of the actual history, which saw Zionism arrive on the soil of a Palestine that was already in the midst of its own modernization." The Zionists, he states, deployed "the conquest of labor" and then "the conquest of the land" to increasingly powerful effect once the British conquered Palestine in 1917"

I have heard this particular talking point from various radical left professors who have almost inexplicably cast their lot with misogynistic, gay hating, democracy hating, female genital mutilating, child bride abusing, murderous thug terrorists! I am a child of the left. I attended my first civil rights march at the age of ten. My first presidential campaign was for Jack Kennedy and my second was for Bobby. You can still find my blog supporting Barack Obama's first election on the Huffington Post. To have people who proclaim that they are for the universal rights of man, for equality of the sexes, for peace and justice, side with Hamas terrorists and claim their superiority over a Western democracy like Israel, makes me want to puke at the very perversity of the notion.

As the saying goes, everyone is entitled to his own opinion, but not his own facts.

So what exactly was this "soil of a Palestine…already in the midst of its own modernization" when Zionisim arrived? Well let's quote someone who was there, on that very soil a mere fifteen years before Zionism arrived. Mark Twain toured the Holy Land in 1867. Zionism arrived in 1882. What was the soil that Twain, no slouch of a social observer he, saw and described in his book, Innocents Abroad?

In describing the Valley of Jezreel, he states, "There is not a solitary village throughout it's whole extent -- not thirty miles in either direction. There are two or three clusters of Bedouin tents, but not a single permanent habitation. One may ride ten miles, hereabouts, and not see ten human beings."

I mention the Valley of Jezreel in particular, because that's where I was partially raised, went to high school, from whence I went into the army, where I was married, where I taught high school and farmed and wrote and where my first born son, of blessed memory, was born. I know the Valley of Jezreel as well as I know any place on earth. It is the breadbasket of Israel, home to some of the most successful and stunning agriculture on earth. It is alive and bustling with farming villages, schools, colleges, high tech industry, and agriculture R&D that is the envy of the world. It abounds in forests, each tree of which was bought and paid for by Jews around the world, as was the land itself, which was stolen from not one Palestinian, because it was worthless and desolate and sold at inflated prices to the Jews who were so insane they paid handsomely for barren soil, which they turned into paradise through..."the conquest of Labor"!

There was a time when leftists actually praised labor! But this was Jewish labor. Jews working with their hands in backbreaking labor and I am old enough to have actually known that founding generation, and their love of that land which was as bare and desolate as when Twain first visited. They made it bloom through "the conquest of labor." Unlike these pious Academic poseurs, they engaged in backbreaking work to plant forests and create thriving agricultural villages. They were idealistic young students who displaced no one in their "conquest of the land," which any enlightened progressive today should realize was carried out by the oldest and most effective ecological society in the world, The Jewish National Fund, which saw to it that Israel was the only nation on earth to enter the twenty-first century with more trees than it had in the century before. And you creeps dare to distort that into some kind of crime!

Here's is Twain's description of the Galilee before the arrival of Zionism: "These un peopled deserts, these rusty mounds of bareness, that never, never, never do shake the glare from their harsh outlines...; that melancholy ruin of Capernaum, this stupid village of Tiberias, slumbering under six funereal palms...A desolation here that not even imagination can grace with the pomp of life and action." That was the Galilee then. Visit it today and be amazed at "the pomp of life and action" all of which was brought in through the conquest of labor of the Zionist Jews literally reclaiming the land from the desert it had become.

Regarding Israel's acceptance of the 1947 UN partition plan and the Arab/ Palestinian rejection of same, the professor states, "The Zionist leadership ‘accepted’ the terms of the 1947 Partition Plan. In reality, they had little intention of actually fulfilling them, and over the next year, through inter communal conflict and then all out war, three quarters of a million Palestinians were permanently forced from their homes,"

Again the intellectual dishonesty by a supposed academic is simply staggering.

Here are the facts:

There never was a state of Palestine. Never. Not once in history. Prior to WW I, what is called Palestine, which comprised Israel of today, Gaza, Judea and Samaria and all of Jordan, comprised a sleepy backwater province of the Ottoman Empire. The Ottomans sided with the Germans, In WW I, and for those who don't remember, they lost the war. The League of Nations, forerunner of the UN, broke up the old Ottoman empire and at the San Remo Conference of 1921, passed a resolution "In favor of the establishment of a national home for the Jewish people…." The resolution went on to state. "Whereas recognition has thereby been given to the historical connection of the Jewish people with Palestine, and to the grounds for reconstituting their national home in that country..." the resolution went on to appoint Britain to have a mandate over Palestine, which "shall be responsible for placing the country under such political, administrative and economic conditions as will secure the establishment of the Jewish national home.... The Mandatory shall be responsible for seeing that no Palestine territory shall be ceded or leased to, or in any way placed under the control and Government of any foreign power."

That last point is particularly important because Britain, in contravention of its duties as a mandatory power, lopped off the bulk of the territory and created out of whole cloth, with 70% of what was to have been the Jewish National home, a Palestinian Arab country, and called it Transjordan, which today is known simply as Jordan. But under international law it was to have been part of "The Jewish National Home"!

In 1936, following Arab massacres of ancient Jewish communities in Hebron and Safed, the British appointed the Peel Commission, which offered to partition the 30% of remaining land into two states; one Jewish and one Arab. Two thirds of the state would have gone to the Palestinian Arabs and one third to the Jews. The Palestinian Jews accepted the plan and the Arabs, who called themselves Arabs, and not Palestinians, again led by Haj Amin Al Husseini, rejected it. The Jews accepted this tiny enclave for one reason. It was 1937 and they knew what was about to happen to the Jews of Germany and Europe. When Hitler wanted to rid Europe of its Jews, not one country in the world would take them in and they literally went up in the smoke and ash of the crematoria of Hitler's death camps. Had Israel been born, even in it's Lilliputian form in 1937, six million Jews and all their descendants would have been alive today.

But, say the esteemed academic supporters and enablers of Hamas and their ilk, that just proves their point. The Palestinians had no part in the Holocaust, and yet they were made to pay the price by accepting into their midst the European survivors of European mass murder, that had nothing to do with them.

Really? Really?

Here are the facts, yet again, troublesome as I know they are.

When Britain went to war against Nazi Germany, the Jews of Palestine rushed to enlist in the British Army and eventually formed the Jewish Brigade which, together with its predecessor Jewish Palestinian units, fought valiantly in North Africa and in Europe, and played their part in the defeat of Nazi Germany.

And where was Haj Amin Al Husseini, the revered leader, indeed founder, (and uncle of Yasser Arafat) of the Palestinian Arab National Movement?

He was Hitler's poodle in Berlin.

So don't peddle this revisionist crap that the Palestinians had no part in the extermination of European Jewry and Nazi war crimes, because their leader Haj Amin Al Husseini sure as hell did!

He met with Mussolini and Himmler and Eichman and Hitler himself.

He joined the Nazi war effort by helping recruit Muslim units under German SS command that were responsible for mass murders in Croatia and Hungary.

Indeed Yugoslavia sought to have Haj Amin Al Husseini indicted for war crimes for his role in recruiting 20,000 Muslims, who participated in mass murders of Jews and others in Central Europe. In 1944, on Radio Berlin, Haj Amin Al Husseini, the father of the Palestinian National movement said, "Arabs, rise as one man and fight for your sacred rights. Kill the Jews wherever you find them! This pleases God, history and religion!"

He issued a statement saying, “Those lands suffering under the British and Bolshevik yoke impatiently await the moment when the Axis powers will emerge victorious. We must dedicate ourselves to unceasing struggle against Britain, that dungeon of peoples."

That's what the leader of the Palestinian Arabs was doing when my foster father and the other members of His Majesty's Jewish Brigade were fighting and defeating the Nazis in Europe.

As to the 1948 War of Liberation, far from being invaded by five surrounding Arab countries determined to make the Mediterranean red with the blood of the Jews, the professor claims that the Arab forces were minimal and badly trained and equipped, and were sent to prevent themselves from looking like collaborators, and to prevent their rival, Haj Amin Al Husseini, "from establishing a state".

Wait a second! Did this Bozo just say the Arab armies invaded the nascent state of Israel to prevent the establishment of a Palestinian state?

You bet. That's what he said. The Arabs, not the Israelis, prevented the establishment of a Palestinian state.

Egypt conquered Gaza and annexed it, without giving its inhabitants benefit of Egyptian citizenship.

Jordan annexed the West Bank and all the Palestinians there became Jordanian citizens. And by the way, no one at the time suggested ever turning those lands into a Palestinian state. At those times when they referred to occupied territory, they were talking about, and Hamas still talks about, Tel Aviv!

As to how badly trained and equipped the poor five invading Arab armies were...no less an expert than General George Marshall, Chairman of the Joint Chiefs during WWII and President Truman's most trusted advisor, said that if the Jews declared independence they would be wiped out within two weeks. And he was right to think so. The "poorly equipped" Egyptians had a 10,000 man armored column less than an hour and a half drive from Tel Aviv. There was not one Israeli soldier between them and Israel's largest city. On the next morning they would drive into Tel Aviv and the two thousand year old dream of a Jewish state would be over. And what did those colonialist, imperialist, pig, Zionists have, with which to fight that 10,000 man armored column?

They had four Czech-built ME 109 fighter planes which had been smuggled into Israel in pieces, re assembled in hangars, had never been test flown, had never had their weapons test fired, possessed neither avionics nor radios so the pilots had to communicate with each other with hand signals, and for aeronautical charts had Palestine Auto Club road maps and boy scout compasses glued to the dashboards.

I know because I am privileged to know the man who led the attack of those four ME109s. He refers to me as his younger brother and it is one of the greatest honors of my life to be counted as his friend. His name is Lou Lenart. He and his three other pilots were told that the fate of the Jewish state rested on their shoulders. They were to take off and stop that armored column. If they failed, Israel was dead. Lou pulled out onto the tarmac, looked behind him at the three other planes and saw the entire Israeli Air Force.

But they did it.

They stopped the Egyptian column dead in its tracks and bought Israel the time it needed to survive.

Of the four pilots, they suffered fifty percent casualties on their first mission.

In Israel's war of Liberation in 1948 it lost one percent of its population killed. That would be the equivalent of America losing three million killed in one year. America has lost a little over one percent of that number in ten years of combat and they say America is “war weary.” What do you think Israel was?

Finally, these mouthpieces for terrorist thugs, wrapping themselves in the robes of Academia, claim that it was Israel that started this current war, and not Hamas.

But that's quite simply a lie.

And we know it's a lie because Hamas did not start digging those thirty two terrorist attack tunnels when Israel started it's aerial campaign against them. Those tunnels were an offensive weapon which was to have handed Hamas their "shock and awe," their 911 moment that would have brought Israel to its knees. They began digging those tunnels five years ago with the cement and steel they stole from their own people, with the cement and steel that was meant to rebuild Gaza, to build schools and hospitals and prenatal clinics. And instead they used it to build terrorist attack tunnels under Israel's internationally recognized 1967 border, aimed exclusively against Israeli civilians, whom they would have murdered, maimed and taken hostage by the dozens. This was their offense, planned and executed at the time of their choosing. But following their doctrine of carrying out terrorist attacks and then claiming the mantle of victimhood, with so called academics as their mouth pieces and enablers, they had to make it look like it was a response to Israeli aggression. So they publicly ordered the kidnap murder of three Israeli schoolboys on their way home from school.

And Israel didn't fire a shot into Gaza. They just engaged in a campaign to round up Hamas terrorists in Judea and Samaria, where the boys had been kidnapped and killed.

Then Hamas started firing rockets at Israel and Israel said repeatedly, “Calm will be answered with Calm."

They must have thought to themselves, " What's a guy got to do to start a war with these Jews?"

Then they upped their rocket attacks to a hundred a day and Israel still said "calm will be answered with calm" while they began their aerial campaign.

Finally a ceasefire was to have taken affect.

Israel accepted it.

Hamas rejected it by launching a major rocket barrage, and then the first of six terrorist tunnel attacks, and that's when Israel had no choice but to respond with a ground invasion to take out what was indeed an existential threat.

Of the 1800 Palestinians killed in this conflict, 1600 of them would be alive today if Hamas had only accepted the cease-fire Israel accepted immediately and unconditionally.

But as I said, they weren't interested in a cease-fire.

This was their war and they thought they could win it.

And don't you buy the crap so-called academics are peddling, that Hamas was the duly democratically elected government of Gaza. Hamas took power, not in an election, but in a bloody coup, machine gunning their fellow Palestinians, blindfolding, binding and throwing them off of multi story buildings. They have terrorized their own people, not only Israel. Their people, indeed, live under the yoke of occupation, but not by Israel, by Hamas.

And as for the apologists and enablers of Hamas, who contribute to the misery of Palestinians and Israelis alike, while sitting in their club chairs in the faculty lounge, may I suggest that from now on they speak only through the orifice which Mr. Voight has so eloquently enlarged for them, since what they are peddling is pure, unadulterated crap.

4:00
HIMSS Europe6 - 7 October 2014, Rome, Italy.
The HIMSS Europe CIO Summit has now established itself as the annual European CIO Summit. For the 5th time, leading European IT Directors and Senior Healthcare IT Executives gather together during the two days, exclusive event to recognize the best use and adoption practices for healthcare IT in Europe.
2:30
This appeared late last week.GPs slam PCEHR in secret report14th Aug 2014Flynn MurphyTHE personally controlled e-health record is running chiefly on “goodwill”, and time-poor GPs say they have little reason to embrace it in its current form, according to a confidential report of the National E-Health Transition Authority (NEHTA) obtained by MO.The report, dated 5 June, is a clinical impact assessment of the integration of e-health into primary care. It was prepared for a NEHTA program established to address major functionality and usability issues in the PCEHR.Fifty-seven general practices responded to an expression of interest to take part, but 10 did not respond to emails or phone calls, six withdrew interest and four were ineligible because they weren’t using the PCEHR.NEHTA ultimately received 35 completed questionnaires and selected 14 practices for face-to-face interviews.Respondents said the time outlay was “onerous”; patients who had records did not know what they had signed...

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All

August 18,2014

22:17


A typical day at work...from I Love Lucy, first aired September 15, 1952

There are days when the grind feels a lot like Lucy's candy factory as seen in the clip above. But the beat goes on, the images keep coming, and they have to be read. As one of my professors used to say, "Miss 'em slow, or miss 'em fast, boys!" Of course, that was a joke. Of course it was. Definitely.

You probably know the difference between sensitivity and specificity. In essence, sensitivity is the percentage of the time you find something that is actually present. Specificity is the percentage of the time you don't find something when nothing is there. In other words, were I 100% sensitive, I would find every cancer that comes through on the PACS worklist. Were I 100% specific, everyone I declare negative will truly be without disease. Put in tabular form (courtesy of Penn State's online Stat course):

I want all my positives and negatives to be true, with no false positives (saying there is disease when there isn't) or false negatives (saying there is no disease when there is.)

There is a whole science surrounding this stuff. Everyone, and particularly every radiologist, has a different set of sensitivities and specificities, and this is all wrapped up in a concept called Receiver-Operating Characteristics, or ROC. From MediCalc:


In a Receiver Operating Characteristic (ROC) curve the true positive rate (Sensitivity) is plotted in function of the false positive rate (100-Specificity) for different cut-off points. Each point on the ROC curve represents a sensitivity/specificity pair corresponding to a particular decision threshold. A test with perfect discrimination (no overlap in the two distributions) has a ROC curve that passes through the upper left corner (100% sensitivity, 100% specificity). Therefore the closer the ROC curve is to the upper left corner, the higher the overall accuracy of the test (Zweig & Campbell, 1993).
Got it? Just remember that everybody's ROC is going to be different, with different blends of sensitivity and specificity.

Fellow radiologist and wannabe writer Saurabh Jha, M.D., takes the concept one step further with his "fictional" colleagues, Drs. Singh and Jha. I'm guessing the second isn't fictional at all, and I'm sure he based the first on someone he knows.  Anyway, Dr. Jha wrote this piece published in the Healthcare Blog, and republished by KevinMD, and also cited by several radiologist friends of mine.

Who Is the Better Radiologist?
By SAURABH JHA, MD

There’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes.

In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician?

Let’s consider two fictional radiologists: Dr. Singh and Dr. Jha.

Dr. Singh is a fast reader. Her turn-around time for reports averages 15 minutes. Her reports are brief with a paucity of differential diagnoses. The language in her reports is decisive and her reports contain very few disclaimers. She has a high specificity meaning that when she flags pathology it is very likely to be present.

The problem is her sensitivity. She is known to miss subtle features of pathology.

There’s another problem. Sometimes when reading her reports one isn’t reassured that she has looked at every organ. For example, her report of a CAT scan of the abdomen once stated that “there is no appendicitis. Normal CT.” The referring physician called her wondering if she had looked at the pancreas, since he was really worried about pancreatitis not appendicitis. Dr. Singh had, but had not bothered to enlist all normal organs in the report.

Dr. Jha is not as fast a reader as Dr. Singh. His turn-around time for reports averages 45 minutes. His reports are long and verbose. He meticulously lists all organs. For example, when reporting a CAT of the abdomen of a male, he routinely mentions that “there is no gross abnormalities in the seminal vesicles and prostate,” regardless of whether pathology is suspected or absence of pathology in those organs is of clinical relevance.

He presents long list of possibilities, explaining why he thinks a diagnosis is or is not. He rarely comes down on a specific diagnosis.

Dr. Jha almost never misses pathology. He picks up tiny lung cancers, subtle thyroid cancers and tiny bleeds in the brain. He has a very high sensitivity. This means that when he calls a study normal, and he very rarely does, you can be certain that the study is normal.

The problem with Dr. Jha is specificity. He often raises false alarms such as “questionable pneumonia,” “possible early appendicitis” and “subtle high density in the brain, small punctate hemorrhage not entirely excluded.”

In fact, his colleagues have jokingly named a scan that he recommends as “The Jha Scan Redemption.” These almost always turn out to be normal.

Which radiologist is of higher quality, Dr. Singh or Dr. Jha?

If you were a patient who would you prefer read your scan, the under calling, decisive Dr. Singh or the over calling, painfully cautious Dr. Jha?

If you were a referring physician which report would you value more, the brief report with decisive language and a paucity of differential diagnoses or the lengthy verbose report with long lists on the differential?

If you were the payer which radiologist would you wish the hospital employed, the one who recommended fewer studies or the one who recommended more studies?

If you were a hospital administrator which radiologist would you award a higher bonus, the fast reading Singh or the slow reading Jha? This is not a slam dunk answer because the slow-reading over caller generates more billable studies.

If you were hospital’s Quality and Safety officer or from Risk Management, who would you lose more sleep over, Dr. Singh’s occasional false negatives or Dr. Jha’s frequent false positives? Note, it takes far fewer false negatives to trigger a lawsuit than false positives.

I suppose you would like hard numbers to make an “informed” decision. Let me throw this one to you.

For every 10, 000 chest x-rays Dr. Singh reads, she misses one lung cancer. Dr. Jha does not miss a single lung cancer, but he recommends 200 CAT scans of the chest for “questionable nodule” per 10, 000 chest x-rays. That is 200 more than Dr. Singh. And 199/ 200 of these scans are normal.

I can hear the siren song of an objection. Why can’t a physician have the sensitivity of Dr. Jha and the specificity of Dr. Singh? The caution of Jha and the speed of Singh? The decisiveness of Singh and the comprehensiveness of Jha?

You think I’m committing a bifurcation fallacy by enforcing a false dichotomy. Can’t we have our specificity and eat it?

Sadly, I’m not. It is a known fact of signal theory that no matter how good one is, there is a trade-off between sensitivity and specificity. Meaning if you want fewer false negatives, e.g. fewer missed cancers on chest X-ray, there will be more false positives, i.e. negative CAT scans for questioned findings on chest X-ray.

Trade-off is a fact of life. Yes, I know it’s very un-American to acknowledge trade-offs. And I respect the sentiment. The country did, after all, send many men to the moon.

Nevertheless, whether we like it or not trade-offs exist. And no more so than in the components that make up the amorphous terms “quality” and “value.”

Missing cancer on a chest x-ray is poor quality (missed diagnosis). Over calling a cancer on a chest x-ray which turns out to be nothing is poor quality (waste). But now you must decide which is poorer. Missed diagnosis or waste? And by how much is one poorer than the other.

That’s a trade-off. Because if you want to approach zero misses there will be more waste. And if we don’t put our cards on the table, “quality” and “value” will just be meaningless magic talk. There, I just gave Hollywood an idea for the next Shrek, in which he breaks the iron triangle of quality, access and costs and rescues US healthcare.

If I had a missed cancer on a chest x-ray I would have wanted Dr. Jha to have read my chest x-ray. If I had no cancer then I would have wanted Dr. Singh to have read my chest x-ray. Notice the conditional tense. Conditional on knowing the outcome.

In hindsight, we all know what we want. Hindsight is just useless mental posturing. The tough proposition is putting your money where your mouth is before the event. Before you know what will happen.

This is the ex-ante ex-post dilemma. In case you want a clever term for what is patently common sense.

Dr. Singh is admired until she misses a subtle cancer on a chest x-ray. Then Risk Management is all over her case wondering why? How? What systems must we change? What guidelines must we incorporate?

Really? Must you ask?

Dr. Jha, on the other hand, is insidiously despised and ridiculed by everyone. All who remain unaware that he is merely a product of the zero risk culture in the bosom of which all secretly wish to hide.

The trouble with quality is not just that it is nebulous in definition and protean in scope. It can mean whatever you want it to mean on a Friday. It is that it comprises elements that are inherently contradictory.

Society, whatever that means these days, must decide what it values, what it values more and how much of what it values less is it willing to forfeit to attain what it values more.

Before you start paying physicians for performance and docking them for quality can we be precise about what these terms mean, please?

Thank you.
So what is quality? I guess getting it right every time would be a good start. But that really isn't in the realm of human performance. No one has a vertical ROC curve. If you read enough X-rays and scans, you will miss something. The old saying goes that the only way not to miss anything is not to read anything. That's not very practical.

Our fictional Dr. Singh misses one lung lesion for every 10,000 studies read. Let's say that she reads 200 studies per day; she will miss something every 50 days, every two months or so. Is this acceptable? Frankly, it is fantastic. A rate within acceptable human parameters would be more like missing something on one of every one hundred exams, something like once or twice a day. Is this acceptable? Not, I suppose, if the lesion is in your chest, or your relative's. But it is a completely reasonable number for a flawed human being. Average radiologist miss rates have been quoted at anything from .1% to 30%. An ACR presentation based in part on Dr. David Yousem's materials reveal the following uncomfortable facts:
  • Radiologists error rate reported at 30%
  • >70% perceptual
    • abnormality is not perceived, i.e. “missed”
  • <30% cognitive
    • Abnormality is perceived but misinterpreted
  • Error does not equal negligence
    • Negligence occurs when the degree of error exceeds an accepted standard
  • Missed diagnoses are the major reason radiologists are sued 
    • Most commonly missed: 
      • Cancers (breast and lung are the largest percentacge) 
      • Spine fractures 
  • Retrospective error/miss rate averages 30% (i.e. hindsight is 20-20) 
  • “Real-time” error rate in daily practice averages 3-5%
So back to sensitivity and specificity. Is it possible to be 100% sensitive and find every single lesion, never having a false negative? Yes, if you read VERY slowly and call everything positive, then yes, you will pick up every cancer, but in the process, you will prompt a lot of unnecessary negative scans (and a lot of anxiety) for all the little dots that weren't really cancers after all. This is the fictional Dr. Jha, and no one appreciates him, it seems. Can you be 100% specific, never having a false positive, and never send anyone on to an unneeded followup scan or biopsy? Sure, and then you get sued when you do miss something. And you will. I've heard it said that sometimes the lesion and the radiologist simply never meet. True enough.

The bottom line is that human beings (and their ROC curves) are anything but perfect. We can try to seek perfection by applying quality metrics and such, but in the end, what do we achieve? Possibly an outlier will come to light, someone whose miss rate is well beyond his or her colleagues, or perhaps well below the rest for that matter. So in the end, this implied rating process accomplishes nothing more than the perpetuation of the fiction of our perfection. Which raises impossible expectations in our patients, and sets the trial lawyers to licking their collective chops. After all, how can we possibly tolerate anything less than perfection? Because perfection doesn't exist.

I've told you the story of Mar-Mar, my Mother-In-Law, and her untimely passing, which was assisted by a radiological miss. My musings at the time are apropos for this discussion:
I've got enough friends who happen to be litigators to know that two things drive a malpractice suit: anger and greed/envy, and they go hand-in-hand. (And as an aside, the majority of cases appear to reach the attention of a lawyer because ANOTHER DOCTOR told the patient that something wasn't done as well as HE would have done it.) As with the young lady driving the beat-up car, an accident or even an incident that approaches such is enough to promote rage in some of us, perhaps even most of us. It doesn't matter that the act was unintentional. I did not set out yesterday to trash some kid's little red jalopy. I think it's also reasonable to say that no physician decides some morning to cause harm to his patient. A missed finding, like a parking-lot collision, is an accident. It is not meant to happen, and everyone would prefer that it doesn't. This is where greed and envy can augment the madness of rage. The young lady above, at some level, realized that my truck was likely worth 8-10 times what her beater might bring, and no doubt this got her all the more riled. Why should that doofus have a nice car? Who gave him the right to almost plow into me? He must think he owns the road, having an expensive car like that. I'll show him!

In the case of a miss or other adventure in medical errors, I think the same thing applies, although certainly with a little more justification. There is clearly a relationship between doctor and patient. If something goes wrong, the patient feels betrayed And the patient gets angry. Given the perception of docs as wealthy, the next step in the mental equation may become: he hurt me (or could have hurt me) and he's going to pay! He can afford it!

While a financial award could put a car back together again, it may not be able to fix what was broken by the medical error. Somewhere along the way, our society has decided that money can compensate for the damage, and maybe that is true. However, juries of our "peers" are wont to award huge sums as punitive measure to "punish" the "bad" doctor. And let us not forget the fact that the litigator might receive 30-50% of the proceeds.

This is wrong. The whole scenario is horrible, and accomplishes nothing but padding the pockets of the litigating AND the defending lawyers. It leads to millions and billions of dollars spent for "cover your ass" procedures and tests. And it's all predicated on the anger over an accident and the thought that there might be a gold-mine to be had having won the malpractice lottery. This must stop.

I want this to be Mar-Mar's legacy: we must forgive those who make honest mistakes. We need to remove anger, greed and envy (and lawyers) from the equation, and somehow set up some entity, some body or board, that would determine actual damages and arrange for those to be made as whole as possible, but without multi-million dollar punitive, redistributive, awards. I know this is next to impossible, as there is way too much money to be made by trying "rich" doctors in front of a jury of their "peers" who would love nothing more than to sock it to them. But it is the right thing, and all but those who profit from the malpractice industry, not just the lawyers, but the plaintiff whores who sell their testimony, know that I'm spot on. Mar-Mar would approve.
Hopefully the above discussion of sensitivity and specificity brings this all full-circle. You can see the pressures under which we operate. We are to produce the work with decisive reports one after the other after the other, functioning as Dr. Singh, but we are never to miss anything, wearing the Dr. Jha hat. Why not just do both? Because we are human and humans can't do that.

No doubt Elliot Siegel will eventually teach Watson the Computer to read imaging studies, and then we will achieve perfection. Well, maybe not. But I'd like to see the litigators sue IBM instead of us.
15:37

A recent press release about the collaboration between GenoSpace and Caris Life Sciences got me thinking about the future of the management of cancer genomics information (see: Caris Life Sciences collaborates with GenoSpace to advance cancer care through research). Below is an excerpt from it:

Caris Life Sciences...announced a collaboration with GenoSpace, a Massachusetts-based technology company that develops robust software solutions for genomic and health data. Caris will apply GenoSpace's population analytics offerings to uncover and better utilize key insights from the company's... tumor profiling service....The partnership also leverages GenoSpace's analytics architecture expertise to unlock key treatment insights from the Caris Registry, a database of clinicopathologic and outcome variables from consenting patients whose tumors underwent multi-technology profiling by Caris.... Caris' tumor profiling databases are comprised of multiple assay technologies performed in combination to achieve [a]...molecular profile of a tumor. The resulting analysis and insights, enabled in part by this collaboration, will create a HIPAA-compliant informatics platform that provides Caris' institutional partners the ability to investigate institution-specific profiling data....It also allows Caris to more efficiently and expediently isolate novel and/or critical drug-biomarker associations, ultimately providing better treatment information to oncologists and their patients.

We see here a collaboration between GenoSpace with its cancer genomic support and profiling tools and Caris with its cancer profiling technology. This relationship suggests to me that a new computing model is evolving for cancer genomics that is different from the preexisting LIS computing model. Here are short descriptions of the two models for comparison purposes:

  • Older classic LIS model: LIS software installed in hospital => LIS receives and stores patient-specific data generated in the hospital labs => LIS reports data to hospital clinicians for analysis, usually these days via the EHR.
  • New cancer genomics model: for-profit companies develop cancer genomic profiling databases and analytic software that runs in the cloud => hospital labs upload individual patient tumor genomic data to this diagnostic cloud node => individualized patient interpretive reports are generated in the diagnostic cloud node => PDF reports are viewed by hospital clinicians via EHR web readers or hand-held tablets or smart phones.

Most of the processing in this new model takes place in the cloud. Reports are generated under this new model using sophisticated databases, analytic software, and algorithms that may not be available to hospital labs. This data and software non-availability is related, in part, to its status as the intellectual property of the genomic reference labs. Moreover, the software and data is also in a state of flux as the pool of knowledge about cancer genomic changes. In the old model, patient databases were created at the hospital level by analyzing patient serum samples that were then interpreted by pathologists and the test-ordering clinicians. In the new model, some of the information necessary to interpret the patient test results belongs to the vendor.

Painting with broad brush strokes, here is the IT architecture I see evolving to manage cancer genomic data, a process separate from hospital EHRs and LISs. The job of the EHR is largely to replicate the paper medical record, to document work flow pertaining to patients, and also to aggregate relevant clinical data generated at the hospital level. The IT nodes that provide cancer genomic analysis exist only in the cloud. In most cases, the hospital clinicians will access the cancer genomic reports for their patients via web readers supported by the EHR or via hand-held tablets and smart phones. Similar and parallel sophisticated cloud diagnostic nodes will also evolve for other diagnostic services like cardiology and radiology.

It may be relevant to refer to these specialized, cloud-based, diagnostic, computing nodes as SMAC diagnostic nodes (see: Time to SMAC the Healthcare Consumer). The term SMAC was described by John who blogs over at Chilmark Research in the following way:

SMAC – Social [i.e., Personalized], Mobile, Analytics, Cloud – is a popular framework for optimizing business performance through IT. The basic idea is that these four elements all play key roles in generating value from data through capture, storage, and application. Social [i.e., Personalized] refers to the consumer or end-user level, where data is created and collected. Mobile describes the shift to smartphone and tablet-driven computing. Analytics speaks to the growing ability and need to interpret and understand data big and small. Cloud refers to the advent of virtual computing through untethered storage and access to data, applications, services, and more.

15:22

The headline of a tech startup blog I read pretty regularly caught my attention today, “Another day, another Chinese hack: 4.5M medical records reportedly accessed at national hospital operator“. The title seems to say it all. It’s almost like the journalist sees the breach as the standard affair these days. Just to be clear, I don’t think he thinks breaches are standard in healthcare, I think he thinks breaches are standard in all IT. As he says at the end of the article:

Community Health Systems joins a long list of large companies suffering from major cybersecurity breaches. Among them, Target, Sony, Global Payment Systems, eBay, Visa, Adobe, Yahoo, AOL, Zappos, Marriott/Hilton, 7-Eleven, NASDAQ, and others.

Yes, healthcare is not alone in their attempt to battle the powers of evil (and some not so evil, but possibly dangerous) forces that are hacking into systems large and small. We can certainly expect this trend to continue and likely get worse as more and more data is stored electronically.

For those interested in the specific story, Community Health Systems, a national hospital provider based in Nashville reported the HIPAA breach in their latest SEC filings. Pando Daily reported that “Chinese Hackers” used a “highly sophisticated malware” to breach Community Health Systems between April and June. What doesn’t make sense to me is this part of the Pando Daily article:

The outside investigators described the breach as dealing with “non-medical patient identification data,” adding that no financial data was stolen. The data, which includes patient names, addresses, birth dates, telephone numbers, and Social Security numbers, was, however, protected under the Health Insurance Portability and Accountability Act (HIPPA).

I’m not sure what they define as financial data, but social security numbers feel like financial data to me. Maybe they meant hospital financial data, but that’s an odd comment since a stack of social security numbers is likely a lot more valuable than some hospital financial data. The patient data they describe could be an issue for HIPAA though.

As is usually the case in major breaches like this, I can’t imagine a chinese hacker is that interested in “patient data.” In fact, from the list, I’d define the data listed as financial data. I’ve read lots of stories that pin the value of a medical record on the black market as $50 per record. A credit card is worth much less. However, I bet if I were to dig into the black market of data (which I haven’t since that’s not my thing), I bet I’d find a lot of buyers for credit card data tied to other personal data like birth date and addresses. I bet it would be hard to find a buyer for medical data. As in many parts of life, something is only as valuable as what someone else is willing to pay for it. People are willing to pay for financial data. We know that.

We shouldn’t use this idea as a reason why we don’t have to worry about the security and privacy of healthcare data. We should take every precaution available to create a culture of security and privacy in our institutions and in our healthcare IT implementations. However, I’m just as concerned with the local breach of a much smaller handful of patient data as I am the 4.5 million medical record breach to someone in China. They both need to be prevented, but the former is not 4.5 million times worse. Well, unless you’re talking about potential HIPAA penalties.

3:00
Siemens HealthcareSiemens Healthcare plans to divest its hospital information system business (HS) for US$ 1.3 billion (around €963 million) in cash to the US-based company Cerner Corp. The HS business is focused on administrative hospital IT and electronic patient records, thus different from information technology that enhances the capabilities of imaging modalities and laboratory equipment.
2:30
Here are a few I have come across the last week or so.Note: Each link is followed by a title and a few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.General CommentQuite an interesting week with all sorts of amusement on the consultation regarding the PCEHR and the HIC Conference revealing that morale in the e-Health sector is less than ideal with the credibility of the those who are leading the e-Health Program failing to generate much in the way of confidence in their leadership. Will be interesting to see how things play out.Enjoy the articles.-----http://www.allens.com.au/med/insights/insightsaugXIV.pdfImplementation of Australia's PCEHR system reviewedBy Michael Morris (view CV) and Phil O'SullivanAt the end of 2013, the Federal Minister for Health announced a panel review into Australia’s Personally Controlled Electronic Health Record (PCEHR) system to...

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All

August 17,2014

23:30



We've all heard the hype about Google Glass, but bleeding-edger though I am, I have not yet succumbed to the pressure to invest $1,500 in the future of the future. Fortunately, a friend in the healthcare software business has allowed me to borrow his for a prolonged trial. My conclusion? Nice first effort, Google, but it needs some work.

I'm not going to attempt a full review of Glass, nor will I dabble in the discussions about privacy and so forth. That's all been done many, many times out there on the web, by folks much more eloquent than I. On the privacy issue, my only real concern would be someone wearing Glass in a public restroom. Otherwise, have at it, Glass-wearers. I try very hard not to do something in public that would embarrass me, video'ed or not. Remember, most every cell-phone has a camera, too.

But back to Glass. Technologically, this little strip of electronics attached to an eyeglass frame is pretty amazing. Specs (pun intended) as outlined in the WiKi include:

Technical specifications[edit]


The Explorer's LCoS display optics use a PBS, a partially reflecting mirror beam splitter, and an astigmatism correcting, collimating reflector formed on the nose end of the optical assembly.[26][27]
(For the developer Explorer units:)
  • Android 4.4 [110]
  • 640×360 Himax HX7309 LCoS display[6][25]
  • 5-megapixel camera, capable of 720p video recording[7]
  • Wi-Fi 802.11b/g[7]
  • Bluetooth[7]
  • 16GB storage (12 GB available)[7]
  • Texas Instruments OMAP 4430 SoC 1.2Ghz Dual(ARMv7)[6]
  • 2GB RAM [111]
  • 3 axis gyroscope [112]
  • 3 axis accelerometer [112]
  • 3 axis magnetometer (compass)[112]
  • Ambient light sensing and proximity sensor [112]
  • Bone conduction audio transducer[7]

In the end, it is a super-duper Bluetooth headset, with the addition of video viewing and a still and video camera. (I had invented the Bluetooth headset camera idea myself in 2008! Too bad I never patented it.) And position sensors, etc., out the wazoo. But an appendage it is, and it needs a smartphone in your pocket to perform all of its tricks, although a WiFi connection will go a long way. This is almost a full-fledged computer system you wear on your face, but it's not quite capable of independent operation. Still, the technology is truly incredible, and quite an achievement for a first-pass.

In actual use, I was not as impressed as I wanted to be. Battery life was horrible, giving me just over an hour of heavy use. Of course, you could bring along a battery pack and cable and keep Glass plugged in. But even if you go to that length, Glass will shut down periodically due to overheating, and it does get quite warm to the touch.

I wear bifocals, and my dominant right eye is more nearsighted than my left. I've reached the age of presbyopia (this actually happened when I was 40 which was quite a while back) so I need close-up correction as well. The Glass display lives somewhere in your right upper outer visual quadrant, and as you can see in the bathroom mirror pic above, one has to look up to see it. To me, the display went in and out of sharpness, and my perceived resolution was fair. Text had to be pretty much full-screen to be readable. The size of the "virtual" screen is about the same as my 70" TV as seen from 20 feet away. But my TV is much sharper. We need some better optical correction.

Control of Glass might be its worst aspect. There are two ways in. First, there is a limited touch pad at the temple piece. You can tap in the manner of a mouse-click, or slide back and forth, evoking a linear menu of sorts, depending where you are in the OS. Stroking down dismisses whatever screen you have up. I'm not terribly impressed with this, but the second input, speech recognition is a deal-breaker for me here as well as in transcription. To be fair, the limited voice commands actually do work, as long as you wait for the proper prompt and begin with "OK, Glass". As in, "OK, Glass, Google why are people looking at me funny?" But therein lies the rub. Out here in the real world, you simply cannot go around talking to yourself and not get funny looks at the very least. It looks odd, it sounds odd, in the work environment it will bother other people, and at a bar it will inspire large gentlemen to assist you in divesting yourself of and ultimately destroying the $1,500 toy. Making a spectacle (ha ha) of myself is something I try to avoid. And think about the joy of having a bunch of Glasses operating in a single room. Which "OK, Glass" will the headset actually believe? There is also a third, limited input, that uses a strong eye-blink to activate the camera. So if a Glasshole winks at you, don't wink back unless you want to see it on Facebook.

Ultimately, Glass attempts to be the interface between the real-world of the user and the virtual world of Google. A laudable goal. However, neither the software nor the hardware itself are quite there, though the potential is obvious. Glass offers connectivity of sight and sound and position. It has a camera which sees what you see, and a display to feed you information visually. The microphone hears what you hear, and the bone-conduction speaker talks only to you. Glass knows where you are (via the phone's GPS) and where your head is. Assembling one or more of these capabilities can yield tremendous power, limited only by the imagination. Google outlines many of the tasks already available, such as Googling (duh) things, asking for directions, taking and sending photos and videos, and making phone calls. While it isn't particularly limiting, Glass lives in the Google universe, and your communications are predicated on using Gmail, Google +, Google Habitats, and Google Porn (gotcha). They all work, but not necessarily my favorite way to do things.

The onboard software and additional Glassware apps (loaded via MyGlass app for iOS or Android) take advantage of one or more of the headset's properties. My favorite is Star Chart, which reveals the secrets of the night sky as you gaze directly at the Heavens (or at your ceiling.) It will focus on the star or celestial body at center screen and verbally describe it to you via the ear-piece. Here, we are using the proprioception and GPS to figure out where you are looking, and the display to show the proper star-map.


I was shooting for Polaris, but by the time I captured the image on the iPhone's MyGlass app, I had moved my head. But you get the idea. See the Big Dipper in the center?

There have been a number or attempts to use Glass in the healthcare field. For the most part, these simply use the camera as a live-feed for sharing operations and such, or the display for piping imaging studies or other data in real-time to the surgeon or whomever needs them. If I may be so bold, these are really mundane applications piped through novel equipment.

My patron, the kind fellow who loaned me his Glass, wanted my impressions of how Glass could be used in Radiology. I'm not sure where he wanted me to go, but I'm going to do my best to think outside the box. And I'll probably disappoint him and you, dear readers.

Being an imager, my first thought was to use Glass to analyze images, perhaps to recognize pathology or to send a scan or slice thereof to a colleague for consultation. But the more I thought about it, the less sense that made. Why add extra links to the imaging chain? Look at the specs of the specs. Yes, the camera is 5MP, but the lens is really, really tiny. I pulled up a CT image from the 'net to simulate this process, and with an "OK, Glass," took a photo of it. (Which prompted Mrs. Dalai to suggest that I TAKE THE DAMN THING OFF AND STOP TALKING TO IT.  See what I meant above?) Anyway, here's what I got with my face about 4 inches from the screen:


OK, Glass, this is workable, although I don't like to stick my face that close to the monitor. The nose-prints get nasty after a while. But does it make sense to do it this way? Not really. We have the full resolution image right there ON THE SCREEN. It doesn't make sense to get the image into the system in a round about way when the image is already in some system. Perhaps the best approach would be to add software to the workstation (or laptop?) itself that talks with Glass. Perhaps the heads up display (HUD) could show a cross-hair to show the software where you are concentrating. But, no, that's foolish too. Point at it with the mouse and be done with it. Maybe we could use voice commands to decide which images to capture? Ummm...why bother? Proper PACS software should make that a lot easier. Scratch that idea.

Similarly, looking at images on the HUD doesn't make a lot of sense. The display has 640 x 360 pixels, or 0.23 MP. And with my eye, it doesn't even look that good. I can miss stuff at 3MP. I don't want to even contemplate what will get by me at less than 10% of that.

You see the pattern. Glass is meant for roaming away from your computer. It has some great possibilities for situations where you don't have access to a "real" computer and particularly a monitor. Glass pales miserably as compared to a proper workstation, and really shouldn't be compared at all. Radiology, being a workstation-based field, at least from my end of it, just does not as yet lend itself to this iteration of wearable technology.

At this point in time, Glass isn't a lot more than an expensive toy for bleeding edgers. It has too many problems and limitations. But it is certainly the first step in a major revolution. We will need to see some major improvements for Glass to be more practical even for its current limited applications. Battery life has to improve, and the interface needs to be trashed and redesigned. I'm not really sure what would work better than the unholy combination of voice and a very limited trackpad, but there has to be something. Maybe using the camera to watch hand motion? Of course, this would bring a new meaning to the term "hand-waving"...

Most important for imaging is the image. The itty-bitty HUD is a technological tour-de-force, but it isn't adequate for my purposes. The optics are not good for me, and several other Glass users have had the same problem. Google will have to improve upon the lensing of this tiny display. I would assume the actual display piece would have to be larger to allow for more pixels, which would add weight and bulk. A stereo display with bilateral HUD's would be wonderful, though incredibly odd-looking. The possibility of a 3D HUD brings to mind some Sci-Fi level approaches, such as superimposing volume-rendered scans over a surgical field. "Cut Here" becomes a reality at last.

OK, Glass. We've had some good times, but I'm afraid it just isn't going to work. Can we still be friends? OK, Glass, I know I was a Glasshole, but it's time to move on. Google it.

20:28

I’ve been looking at hospital supply chain automation and the IT surrounding it for a number of years now. Starting with Cardinal Health but then moving on to help a number of other vendors in the space, I’ve felt that there’s not been enough next-generation tech being applied to the low margin, high volume business of hospital supply management. Hospitals often spend tens of millions of dollars on EHRs and other IT systems that have little direct cost reduction capability but they ignore, often at their peril, supply management systems that can save immediate dollars. There seems to be a light at the end of the tunnel, though. Earlier this year I joined the board of Hybrent, led by founder and supply chain expert Harold Richards, because I instantly saw the value of what they were doing. While Hybrent is a startup funded by a couple of friends that I know have been successful in the past, I joined primarily because of Harold’s 21 years testing, applying, measuring and implementing supply chain strategies that have driven well over $50 million in costs out of the supply chain units where he’s served. While supply chain automation is often seen as an administrative activity, I’ve seen first hand that it’s actually directly tied to increase in patient & nursing satisfaction. I asked Harold to tell us a little about why supply chain automation is so important and here’s what he had to say:

Does Your Hospital Supply Chain Have Traits Of An Ant Farm?

You may have had an ant farm as a child and marveled at the cooperative efforts and precision of the ants as they went about their daily activities. Thanks to the panes of glass, you could see into the inner workings of the ant society at all levels and depths.

That same level of effort went into the anthill in the backyard – maybe even more due to the lack of protection. Yet it went unnoticed because it was underground. You only noticed problems when they affected ants that you could see at the top of the anthill.

So it is with the hospital supply chain, full of hard working individuals who run into daily challenges just as ants do. Both rely on excellent systems of communication to get things accomplished. However, ants do not have to deal with bureaucracy, integrating of mismatched systems, missing supplies and other time-wasting system failures (at least not as far as we can tell).

Front-line healthcare workers do spend precious time dealing with these problems, resulting in inefficiencies, higher costs, and potential poor patient outcomes. Spending 20% of your nurses’ time on supply scavenger hunts does not help anyone – certainly not the nurses.

Not only does this cause inefficient use of time, it causes inventory chaos – incorrect counts, hoarding supplies, missing orders and the like – that can snowball throughout your supply chain system. You have stressed and unhappy ants, so to speak.

These misfires cause turmoil within the ant farm and can lead to accidents like sentinel events.  Looking at the bigger picture within healthcare, we are expected to do more with less. In my opinion this is a recipe for disaster.

Today, droves of patients are flocking to the ER’s like never before seeking treatment. As a result, emergency rooms all over the country are filled beyond capacity levels with less staff, more workload and higher expectations. According to USA TODAY, some hospitals are seeing 12% spikes.  Purely from a metrics perspective this may not seem like much, but could result to patients dying while waiting for care.

With this increase in volume there now becomes a higher risk and demand for medical supplies & enhancement in supply chain efficiencies. The reality we live in is this; incorporating anything less than the traits of an ant farm will cause major mishaps in form of patients dying.  It’s a sentinel event just waiting to happen.

Just imagine something as minor as clinical caregivers not having instant access to trauma, respiratory, and EMS supplies within a already busy emergency department while a patient is being triaged with chest pains. Quite a frightening forecast when you think about it.  As they say, future behavior is predicated upon past behavior.  The future outcomes of your patients weigh heavily on your actions.

As a hospital executive, your view may be that of the backyard anthill – you have surface information that gives you superficial knowledge, but without the overall view you need to fully anticipate or fix problems. Meanwhile, your care providers may be dealing with supply chain systems that hamper effective communication instead of enhancing it.

If you’re not doing these three things your patients are at risk and your hospital is losing millions of dollars in supply chain management:

  1. You must setup a transparent assignable communication system for the front-line staff – A system allowing your “ants” to effectively communicate. With rules and filters that you define, user-friendly menus simplify the ordering process for your nurses and give real–time feedback that propagates through your system via real-time push-notifications and alerts. It’s imperative that everyone from nurses to supply chain personnel to trading partners works off the same set of information.
  2. Compiles data, giving you and your staff immediate access to as much data as you need, based on your preferred settings. This gives you the “panes of glass,” if you will, to see into the complex workings of your system at any point in time. It’s equally important to have this data embedded within daily workflows to effectively make better business decisions.
  3. Be accountable for setting up the rules and analytics that are important to your organization. Sense the need of urgency to prevent as well as fix problems. You can either process the output of the visibility system through a separate analytical engine to get the insight you need, or integrate the two along with any other useful support system.

The key is to get you the information and facts you need to make decisions when you need it, and not to overwhelm yourself with frivolous or useless information. If you can’t see the overall picture, and can’t interpret it, you can’t fix it. That is true at both the executive and care-provider level. Do you really know what’s going on in your “anthill” today?

Ants are models of efficiency, and with a proper Supply Chain Visibility System, your front-line care providers will be as well. They will be thrilled with the ability to streamline their time and prevent supply chain snafus. They will probably forgive you for any ant analogies you want to draw – although you’ll have to gauge that for yourself.

Editor’s note: If you’re wondering what’s going on in your anthill, e-mail Harold to get a free 30 minute Supply Chain “Clarity Session” consultation, which consists of answering a few questions and getting some pretty impressive actionable intelligence in a short thirty-minute call.

 

2:00
Here is my draft submission. Comments are very welcome to improve it.-----PCEHR Review Consultation Submission - DG More - August 2014 IntroductionThe following submission has been prepared to offer some commentary and input to the process now underway, being facilitated by Deloitte, to ascertain stakeholder views on the Personally Controlled Electronic Health Record System (PCEHR) and the recommendations  of the recently undertaken PCEHR Review which was commissioned by the Federal Health Minister in September 2013 and released publically in May 2014. Author Of DocumentThis document is authored by Dr David G More MBBS BSc(Med) PhD FANZCA FCICM FACHI. I have had over 20 years involvement, in one form or another, in the area of Health Information Technology (e-Health) and been a contributor to many projects in the area including the development of the 2008 National E-Health Strategy.I am reasonably well known in Health IT circles as the author of a blog on Health IT...

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All

August 16,2014

21:35
Here are the results of the poll.Do You Believe The Consultation Process Being Conducted By DoH On The PCEHR Is 'Fair Dinkum'?Definitely 4% (2) Probably 2% (1) Neutral 2% (1) Probably Not 13% (6) Of Course Not 79% (37) I Have No Idea 0% (0) Total votes: 47 Very clear cut. 92% do not think the consultation process is ‘fair dinkum’. Again, many thanks to all those that voted! David.

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All

August 15,2014

13:40

Telemedical treatment has been a tantalizing possibility for many years, for reasons including a failure of health plans to pay for it and too little bandwidth to support it, but those reasons are quickly being trumped by the need for quick, cheap, convenient care.

In fact, according to research by Deloitte, 75 million of 600 million appointments with general practitioners will be via telemedicine channels this year alone.

While one might assume that this influx is coming from traditional primary care practices which are finding their way online, that doesn’t seem to be the case.

Instead,a growing number of entrepreneurial startups are delivering primary care via smart phone and tablet, including Doctor on Demand and HealthTap, which offers videoconferences with PCPs, and options like Healthcare Magic and JustAnswer, which offer consumers the opportunity to get written responses to their healthcare queries from doctors.

Primary care doctors going into direct primary care are also joining the primary care telemedicine revolution; a key part of their business is based on making themselves available for consultation through all channels, including Skype/Facetime/Google Hangout meetings.

To date, most of the thinking about telemedicine have been that it’s an add-on service which is far to one side of the standard provision of primary care. However,with so many consumers paying out of pocket for primary care — and virtual visits typically priced far more cheaply than on-site visits — we may see a new paradigm emerge in which victims of  high-deductible plans and the uninsured rely completely on telemedical PCPs.

Rather than being merely a new technical development, I believe that the delivery of primary care via telemedical channels is a new form of ongoing primary care delivery.

It will take some work on the part of the telemedicine companies to sustain long-term relationships with patients, notably the use of an EMR to track ongoing care. And telemedicine PCPs will need to develop new approaches to working with other providers smoothly, as coordination of care will remain important. Health IT companies would be wise to consider robust, unified platforms that allow all of this to happen smoothly.

Regardless, the bottom line is that primary care telemedicine isn’t an intriguing sideline, it’s the birth of a new way to think about financing and delivery of care. Let’s see if traditional providers jump in, or if they let the agile new virtual PCP companies take over.

9:38

I have posted a number of previous notes about obesity (see, for example: No Nation Has Lowered Its Obesity Rate in 33 Years) because I think that it's one of the greatest health threats facing the U.S. as well as around countries. I came across an interesting article that speculates about the primary cause for obesity around the world (see: What’s Behind the Obesity Epidemic? Easily Accessible Food, and Lots of It) and below is an excerpt from it. It's worth reading because of the abundance of evidence it provides for the theory that the cause of most obesity is that food is to inexpensive and accessible.

Among the American public and even some policymakers, it has become conventional wisdom that poverty, a dearth of supermarkets, reduced leisure time, and insufficient exercise are key forces behind the U.S. obesity epidemic. Conventional wisdom is an unreliable guide, however, and in this case, much of it is wrong: The epidemic actually coincides with a falling share of income spent on food, wider availability of fruits and vegetables, increased leisure time, and more exercise among the general population. Of course, there are differences between individuals, but we need to explain the change in obesity over time, not why people differ. Some differences in body mass index (BMI) are associated with genetic makeup. But genes haven’t changed in the past 50 years, so differences between individuals don’t explain trends....The clearest change concerns food availability and cost. Since the 1970s, there has been a significant drop in the share of income spent on food—yet each food dollar buys a lot more....As the obesity epidemic has grown and food prices relative to income have dropped, Americans have been eating more of everything, including fruits and vegetables. In terms of macronutrients, most extra calories come from carbohydrates. U.S. markets have succeeded in largely solving the age-old problem of food scarcity, so the answer isn’t to return to higher food prices across the board. But with the solution to food scarcity contributing to a new threat, Americans need market forces to shift them in a different direction and help stem the obesity epidemic....Under the influence of conventional wisdom, many policy interventions focus on “positive” messages: Eat more fruit and vegetables. Get more exercise. However, given that fruit and vegetable availability and physical activity have both increased while relative food prices have plummeted and obesity rates have soared, reducing discretionary calorie consumption may be a more promising lever to reduce overweight and obesity.

So here is the most important message regarding control of obesity: reduce calorie consumption. This approach is sometimes referred to as portion control (see: Portion control key to fighting obesity, expert says). There are some tricks to this approach to weight reduction such as using smaller plates and avoiding "all you can eat" food buffets. In the final analysis, however, reducing the amount of food eaten requires self-discipline. This is difficult because companies that manufacture various types of foods load them up with the salt, sugar, and fat that we like very much (see: Some Salty Facts Keeping to a Healthy DietThe Harmful Health Effects of Sugar; Next Steps?). I have been told that the theory behind diet programs such as Jenny Craig is portion control. Here's an article about how to learn portion control using the Jenny Craig prepared foods (see: How to Learn Portion Size With Jenny Craig). Learning portion control can be tough in this country, particularly if you commonly eat in fast food restaurants where there are lots of incentives to "super-size" your meal.

August 14,2014

18:00
European CommissionGrabbing a glass or typing an email: these are some everyday gestures that are not possible for people with serious physical impairments - even though they have the will and the brainpower to do so. EU-funded projects such as TOBI (Tools for Brain-Computer Interaction) are working on technologies that could greatly improve the quality of life of people such as 20-year-old Francesco or 53-year-old Jean-Luc.
16:24
An article in Information Week caught my eye this morning. It reviews a new program offered by Texas A&M with support from Dell to help medical students and other healthcare professionals “come to terms with  the ways technology is changing their...(read more)
Source: HealthBlog
11:39

FB post

A girlfriend of mine recently posted the above note on Facebook. Not surprisingly, several women (and a couple of progressive men) expressed similar discontent with the procedure; a couple of commenters said they were sure that a man invented the technology, while another pointed out that more women would likely be compliant with screenings if the process was not so unpleasant.

While I can’t say I love getting a mammogram, there are definitely other aspects of my well-woman check-up that I dislike more.  Lest your mind wander too far from HIT, let me clarify a few of the other annoyances:

  • Filling out multiple forms. My primary care physician and my gynecologist both have Epic. Why can’t they share my information with one another so I don’t have to fill out all this redundant paperwork?
  • No option for online scheduling or checking lab results. As I mentioned in a previous post, I am a fan of patient portals – when they work well. In fairness to my doctor, his group just recently went live on Epic and they have not yet launched their portal.
  • Looking at the backside of my doctor as he reviews my online chart and enters his note. (To be clear, I don’t mind looking at the backside of men as a general rule.)

The problem with mammograms, EMRs, patient portals, and other healthcare technologies is that too often the developers seem to have forgotten the patient experience. Case in point: EMRs. Having all of a patient’s visit record online is a tremendous benefit. Frequently, however, the EMR interferes with the patient exam because the physician seems to be paying more attention to finding the right drop down item than to the actual patient. Especially if I am sick, I want my doctor’s full attention and assurance that he/she is engaged and invested in my care.

I’m not just blaming the software developers.  Some of the blame goes to the government for requiring all the meaningful data that can seem irrelevant to the visit, or items like a multi-page visit “summary” that is too verbose and confusing to be of much benefit to the patient.  I personally love the idea of a visit summary, but it’s painful to read through all the medical jargon and other superfluous data. If I take my daughter to the pediatrician for an ear infection, I’d prefer a one page “summary” that includes a bottom line telling me, 1) give her antibiotics until finished and Ibuprofen for pain, and 2) call the office if symptoms get worse or she is not better in three days.

I am not sure who gets the blame for the whole explanation of benefits mess. I mean, who can glance at one and determine if and how much insurance is paying, if the provider is going to send me an additional bill and for how much, if the carrier is waiting on more detail from the doctor, if the patient needs to follow up with the doctor, etc.? And just when you think you are a semi-expert at reading an Aetna EOB, your employer switches to Humana – which of course has an entirely different EOB format.

Here’s a novel idea: let’s get patients more involved in the whole software design process. Not just those patients who love technology, but also my 79 year-old dad who still uses a phone book to look up phone numbers, or my sweet retired neighbor who loves to do her shopping from mail-order catalogs. I’m not sure how one builds a better mammography machine, but I am sure there are plenty of women out there willing to provide some input.

And yes, we do get to blame – and thank – a man, Dr. Robert L. Egan – for developing the modern-day mammogram

Categories: News and Views , All
10:39

I’ve been getting many questions these days about big data tools and solutions, especially their role in healthcare analytics. I think that unless you’re doing large scale analysis of biomedical data such as genomics, it’s probably best to stick with traditional tried and true analytics tools. Online Analytics Processing (OLAP) can be invaluable for medical facilities to use when interpreting data and health informatics because most of that data is in relational, key-value, or hiearchical databases (such as MUMPS). I reached out to Ron Vatalaro, who works with the University of South Florida Morsani College of Medicine and writes about health informatics, to summarize which commercial tools are good to consider for modern OLAP architectures. Here’s what he said:

Online Analytic Processing (OLAP) is used in computing to quickly respond to multi-dimensional analytical queries. It is a subset of business intelligence, which also includes report writing, relational database, and data mining. OLAP tools make it easy to analyze data from multiple perspectives through one of its following three basic operations: consolidation (roll-up), drill-down, and slicing and dicing.

OLAP and data warehousing are interacting with and shaping health informatics by allowing for new analytical opportunities, in addition to the customary statistical approaches. It is one thing to collect vast amounts of data, but gaining insights as to how to best use the data to save lives and dollars is where the rubber meets the road. It is up to informatics professionals to glean meaningful information from the data sets and OLAP tools make it easier to breakdown and analyze big data.

Clinicians and hospital administrators can analyze the data for both individual patient care and to make optimized decisions to better serve all patients undergoing treatment at the facility. Dimension tables can be vital to testing hypothesis using textual, non-numerical data. For instance if administrators what to determine if the colors of walls or views from the window in patient’s rooms correlate to stay durations, nurse calls or return rates –  these tools can assist in drawing such conclusions.

EHR and OLAP

EHR and OLAP work hand-in-hand to deliver across-the-board improvements in world-wide health reform. It is important to understand the role data plays in the healthcare business model, and in what ways EHR systems are capturing and relaying this data. When it comes to the massive amounts of information coming into the healthcare data infrastructure, the use of comprehensive analysis becomes invaluable. Thus when the output from EHRs can be meaningfully dissected the results can lead to the following benefits: better continuity of care, increased patient participation, enhanced practice efficiencies/cost savings,  better accuracy, reduction of errors and more convenience for patients and healthcare providers.

The story your data is telling can present a double-edged sword. One of the benefits of being able to slice-and-dice down big data is to root out inefficacies; however, these same inefficiencies can lead to loss income due to meaningful use and pay-for-performance (P4P) policies. That being said, it is important to have comprehensive analytics to track and root out potential problems proactively, and to know what data third parties, such as insurers, are also looking at.

There is also the data healthcare providers cannot control, for instance, the decisions among patients to maintain their own health and well-being. There are government and insurance provider-backed incentives that reward “good behavior” among individuals who prioritize their health (not to mention the benefits of a healthy lifestyle). Categorizing and engaging individuals who do not care to advocate for their own benefit through unhealthy behaviors, (such as poor diet, alcohol abuse or tobacco use) and identifying any external factors that may exacerbate these issues (such and geographic, ethnic or socio-economic) can enrich lives and benefit the overall environment of healthcare. In these circumstances EHR and OLAP work together to the mutual benefit of society and the healthcare industry.

OLAP and Pharmacy Systems

To aid in pharmacological data management OLAP can play a major role in using the vast amounts of information from managed care organizations (MCO) management information systems (MIS) in a meaningful way. Information regarding member/provider functions, claims administration, clinical management, rebate administration and financial details are managed by systems generally referred to as online transaction processing systems (OLTP). Such systems have allowed the collection of billions of prescription records year-over-year. However, with the need for massive amounts of data to enable more effective drug therapy treatments, pharmacy management systems can fall short of the necessary processing power. That’s where OLAP systems step in to make decision support tools from the OLTP systems. These tools can interact with the data by making changes to the OLTP system, extracting data from the patient population and the prescribers of the medication.

OLAP Iterations

OLAP systems are classified by the following groupings:

  • Multi-dimensional (MOLAP): Known as the classic form of OLAP, this iteration is often denoted as simply OLAP. Instead of storing data in a relational database, MOLAP uses optimized multi-dimensional array storage. It relies on pre-computation and storage of information in the cube. Tools typically employ a pre-calculated data cube, including all possible responses to a certain range of questions. These tools have a very quick response time and can quickly write back data into the data set. They are useful for data sources that are static, therefore more useful for analyzing information from medical devices, since they operate on pre-determined parameters and are subject to less variability. It also works well for data that is more latent, or less frequently processed.
  • Relational (ROLAP): In this iteration, base data and dimension tables are stored as relational tables and new tables are generated to store the aggregated information. It relies on a specialized schema design that manipulates the data stored in the relational database to make it appear to have traditional OLAP functionality. Rather than using pre-calculated data, tools pose the query to the standard ROLAP database and its tables to bring the necessary data back to answer the question. As this methodology is not limited to the contents of a cube, tools have the functionality to ask any question. This type of analysis is good for information that is dynamic or frequently changing using its star scheme. Therefore, this type of analytic processing is good for information such as patient data, which has many variables and is subject to frequent changes and fluctuations.
  • Hybrid (HOLAP): The hybrid iteration is somewhat of a broad term, with a number of different interpretations, but all agree that a database will separate data between specialized and relational storage. HOLAP combines the capabilities of MOLAP and ROLAP to address their weaknesses. Tools can also use relational data sources and pre-calculated cubes. HOLAP tools can help to understand how patients and devices interact together, especially over time.

5 OLAP Tools Strengths and Weaknesses

There are a wide-variety of data management tools available to assist healthcare organizations in online analytics processing. There are

  • Microsoft: The company’s Microsoft Analysis Services support MOLAP, ROLAP and HOLAP. However, it can only run on a Windows operating system, so organizations using Linux, UNIX, or z/OS won’t be able to use it.One of the benefits to healthcare professionals using the system is that it integrates well with widely used software, such as Excel, that may be more comfortable to use among those with more of a healthcare background than a technical background.
  • Oracle: Oracle offers two OLAP servers ─ Essbase and Oracle Database OLAP Option. In addition to supporting MOLAP, ROLAP and HOLAP, they also support semi-additive measures, write-back, and partitioning. Oracle Database OLAP Option is compatible with Windows, Linux, UNIX, and z/OS, but Essbase cannot run on z/OS. Oracle offers the Service-oriented architecture (SOA) as a part of its data analytics service, which is specifically designed for healthcare integration.
  • IBM: Cognos TM1 is IBM’s OLAP server. While IBM Cognos offers MOLAP, ROLAP, and HOLAP data storage modes, IBM TM1 only offers MOLAP storage. TM1 is compatible with Windows, Linux, and UNIX, but not z/OS. IBM offers an assortment of assistance tools for healthcare data such as DB2 Intelligent Miner, industry specific guides, along with third party support form Blue Line.
  • SAP: The SAP NetWeaver BW is the SAP OLAP server. Semi-additive measures, write-back, and portioning features are supported, but only MOLAP and ROLAP storage modes are offered. SAP offers support tutorials for using their NetWeaver tools for health insurance claim eligibility and health checks such as cholesterol levels.
  • MicroStrategy: The MicroStrategy Intelligence Server offers MOLAP, ROLAP, and HOLAP data storage modes, in addition to MicroStrategy Office and Dynamic Dashboards offline capabilities. It is compatible with Windows, Linux, and UNIX, but not z/OS. MicroStrategy is positioning itself as the go-to platform for healthcare business intelligence, leveraging its mobile capabilities as an asset.

How OLAP fits with ‘Big Data’ Hype

As Shahid mentioned in his introduction, there has been a growing buzz around Big Data in IT (generally). Due to the massive influx of consumer information being shared openly over a variety of platforms, there has been a great deal of demand among businesses to capture that information to try and gain market insights and create customer profiles. This flood of information has many implications in healthcare, as tele-health and interoperability are gaining prominence. However, data quality is not the same a data quantity, and quantity (as the name suggests) is essentially what Big Data is all about.

Being able to capture standardized and actionable insights from large sets of data is the important distinction that OLAP brings to the table. Without the insights that structured data can bring, what you are left with is merely a technology (Big Data), rather than architecture (OLAP). That being said, there are differing schools of thought as to what role OLAP will play in the future of data management. It can be said that OLAP cubes lack the agility that a Big Data solution offers, although the presence of one does not mutually exclude the other.

9:53

The following is a guest post by Vishal Gandhi, CEO of ClinicSpectrum as part of the Cost Effective Healthcare Workflow Series of blog posts.
Vishal Gandhi
Eligibility verification has always been a challenging part of running a healthcare business. However, that challenge has become even more difficult as the Affordable Care Act has caused a wave of newly insured patients along with patients who are switching insurance carriers flooding into physician offices. Verifying and learning the details of the patients’ new insurance policies has created a lot of new work for a clinic’s staff.

In the perfect world, there would be an automatic verification system that would easily look up a patient’s insurance policy and the details of their plan. While some companies are trying to make automatic insurance verification a reality, it’s currently very weak and still requires a lot of human intervention and interpretation. Maybe one day the payers will fix that, but until then it’s important that a practice creates a smooth process for verifying a patient’s insurance. In many cases this includes hours browsing insurance company websites and internet payer portals or waiting on hold for hours a day on automated voice systems or insurance company call trees. Is that the best use of your staff’s time?

I don’t think I need to describe in detail why having the insurance eligibility and plan details as early as possible is important. If you don’t have this information, your ability to get paid by the patient for the services rendered goes down and your claims denials go up. Plus, many of these new insurance policies are high deductible plans where you’ll need to collect a lot more money than usual from the patient. One way to solve this problem is to know how much the patient owes before or at least while they are in the office. The best opportunity to collect from a patient is when they are standing in front of you.

While internal staff can do a great job verifying insurance eligibility and obtaining benefits summaries, this can be a challenging job while handling all of the other front desk or billing duties as well. One solution to this problem is to outsource the eligibility verification task. A list of scheduled appointments is supplied to the outside company and after verifying insurance coverage for the patients they put the coverage details directly into your appointment scheduler. Obviously the key business question here is to compare the cost, timing, and quality of an outside service against the cost, timing and quality of your current staff doing it.

One related challenge that many practices are facing with all of these new and changing insurance policies is the time staff spend educating the patients. Most patients did not spend time really understanding the insurance policy they were buying. They looked at the price and largely bought without reading the fine print. This often means your staff are tasked with sharing the details of the policy and dealing with any fallout. In some ways, this isn’t a new task. However, the volume has increased.

Another solution offices should consider is doing the eligibility verification well before their appointment. Then, using a secure messaging solution the practice can share a patients’ eligibility and plan details including any co-pays and deductibles with the patient before they even arrive at the office. This early communication gives the patient time to call their insurance provider instead of your practice for all the details. Plus, it makes the patient payment expectation clear before the patient even enters your office.

How much time is your office spending verifying insurance? What solutions are you using to improve your eligibility checking and communication workflow?

The Cost Effective Healthcare Workflow Series of blog posts is sponsored by ClinicSpectrum, a leading provider of workflow automation solutions for healthcare. Their Eligibility verification service is a great way to leverage technology and people to solve the eligibility verification problem. ClinicSpectrum also offers a secure messaging product called MessageSpectrum.

9:07



Just in time for Halloween, here are some motion GIF's demonstrating function of various joints.

As reported in the Daily Mail,

They were created by San Francisco-based designer Cameron Drake for his client Weiss Orthopedics.

Mr Drake began by uploading the raw footage to a video editor and trimming the clips so they revealed the precise motions made by the joints.

He then removed the individual patient details using Photoshop.

Once the clips were selected, Mr Drake duplicated the frames so they played on a loop.

'This was an excitement in and of itself as there is not much like it on the web and gave me an opportunity to do something cool,' he wrote on his website.
At birth, babies are born with 350 bones which gradually fuse together to complete the adult skeleton of 260. 
We in the imaging business tend to get a little jaded, but when you stop to think about it, we look inside of people, noninvasively, dozens and hundreds of times per day. It really is amazing.

August 13,2014

1:19

Predictive analytics have been oversold in many areas.  I’m  not saying there’s not good use for looking for patterns and determining outcomes as there is but it is getting to the point to where anyone can create a model and claim “it works”.  When the models are proprietary, there’s no way to check for accurate outcomes and decisions are made on such models. There’s a lot of false positives and nobody questions that element and thus so people are getting hurt when that occurs.  In healthcare we have seen it for years with patterns that look for fraud with false positives when the parameters are nailed down too tight.  That has been going on for years.

There is a direct correlation here with inequality as every time a score is made, and it can’t be verified, folks just assume well it must be right when in fact it is not.  It certainly allows for more data to be sold whenever a score is created as now you have some new data to sell to someone else to assist in their decision making.  I call the Attack of the Killer Algorithms, which it is when flawed data denies consumers access. 

Data Selling and the Direct Correlation To Accelerated Inequality - Epidemic Spreading Like A Virus Moving Money Keeping Corporations Cash Rich and Consumers Cash Poor

It even gets worse as sometimes there’s no science at all with models and data scientists or quants just guess..and consumer is denied access, on a “guess” of a number component of a formula.  This FICO medication adherence is one of those as nobody can replicate the proprietary model.  So you just believe any numbers and stats tossed at you?  We sure have a lot of that today. 

FICO Medication Adherence Scoring Should Be Banned As It’s Quantitated Justifications for Profit That Hurts US Consumers Using Proprietary Algorithms That Cannot Be Replicated For Accuracy or Audited

Almost a couple years ago I agreed with a banker too that due to this fact that half of the analytics purchased will be a waste of investment.  We have too many folks looking for “Algo Fairies” when they don’t exist.   A couple years ago I predicted this too and it’s here today with big data being used out of context with discriminatory practices against consumers as everyone just believes anything tossed at them. 

Big Data/Analytics If Used Out of Context and Without True Values Stand To Be A Huge Discriminatory Practice Against Consumers–More Honest Data Scientists Needed to Formulate Accuracy/Value To Keep Algo Duping For Profit Out of the Game

It’s an interesting world indeed that is ending up to be the undoing of what we have developed as our culture over the years, one side hiding risk and other parts exploiting it.  Is there any balance here when you bring in the error factors that are always there and fictional models?  Of course not and it is making everybody crazy and this give a lot people a big area of control and moves a lot of money to the direction of very few in the US so the land of opportunity tends to shrink a bit.  You have to deal with and try to make sense of the fiction that’s mixed in out here.

Again I have written my share of SQL queries and have been a query monster in search of value in querying everything I could get my hands on and did I find value in everything I queried..NO.  There’s a lot of deception out there on where predictive analytics works and what context the numbers are used.  After the fact you can stir up up any old story just looking at data and really miss what occurred.  I just sat there with disbelief with the recent Facebook and OKCupid data scientist stories and scratched my head on how folks could think they could have any impact there at all.  Code runs hog ass wild and you have no control as it’s there to make money and knows how to grind you day in and day out.

Here’s the cause to create a law to where every data seller would need to be licensed and disclose what kind of data they sell and to who.  Scroll down and watch the 4 videos in the footer and the message in this post will become crystal clear as to what’s really going on behind closed server doors that you can’t see, touch, feel or talk to.  Be a skeptic when you need to be and that’s becoming more frequent today as if you don’t, well you’re “Algo Duped” at your own risk.  BD 

0:41

This is getting to be challenging at times with consumers knowing which is which and for that reason some of them are imageopening up next to each other or in the same building.  Folks are mistakenly going to a free standing ER, where they can get care but it’s going to cost a lot more than an Urgent Care Center. 

Minor care needs should be referred to an Urgent care center but that doesn’t always happen and people get surprised with some very large bills.  Even a respiratory therapist made that mistake and she’s in the business.  The situation in Texas with a couple of firms seems to have caught quite a few people off guard and competition is driving it of course.  BD 


COLLEYVILLE — A First Choice emergency medical center popped up here last year where a Blockbuster Video outlet once stood, near a strip center with an Albertsons supermarket, a Subway sandwich shop and a UPS store.

Where customers once lined up to rent Finding Nemo, they can now be whisked before a doctor before even finishing their paperwork. The gleaming new facility has the latest equipment, from a CT scanner to a portable X-ray. An in-house lab provides quick test results. There are free snacks and a Keurig coffee machine, and a well-appointed children’s examining room that has an original undersea wall mural and cartoons on the TV.

Critics of the doctor- and investor-owned ER centers recommend greater cost transparency to avoid sticker shock when the bill arrives.

Patients who aren’t experiencing a life-threatening emergency should be told in advance that the facility is an ER, not an urgent-care center, said Stacey Pogue of the Austin-based Center for Public Policy Priorities, a nonprofit that analyzes healthcare and other issues affecting low- and moderate-income Texans.

For many families, the decision to go to a free-standing ER is driven by convenience.

http://www.star-telegram.com/2014/08/09/6031491/as-free-standing-ers-business.html?rh=1

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