February 26,2015


In light of yesterday’s short story post, and also my post on EMR and EHR about concierge medicine, I thought it timely for me to document might entrance into what many are calling the next generation of healthcare. They talk about it as primary care that puts people first.

In my case, it’s my recent membership in Turntable Health, an operating partner of Iora Health. When I had to switch insurance plans this year, I decided to try out this new approach to primary care. The insurance plan I chose included a membership to Turntable Health. For those not familiar with Turntable Health, it was started by the infamous ZDoggMD and is backed by Tony Hsieh’s (CEO of Zappos) Downtown Project in Las Vegas.

To be honest, I’m not sure exactly what I’ve gotten myself into, but that was kind of the point. I can’t remember the last time I went to a primary care doctor. In fact, if someone asked me who my primary care doctor was I wouldn’t have an answer or I might mention one that my wife visited. I’m a relatively healthy person (luckily I have some good orthopedic friends for my sports injuries) and so I’ve never felt the desire to go in and see my doctor. I feel healthy, so why should I go and pay a doctor to tell me I’m healthy? I think this view is shared by many.

Will Turntable Health be able to change my view on this? Will they be able to take a true Wellness approach to things that will change how I view primary care? I’ve written for years about Treating a “Healthy” Patient, and so I’m interested to see if Turntable Health is making that a reality.

One thing is for sure. They’re taking a different approach than most doctors. I scheduled my first appointment for later today (Side Note: Not sure what it says that it took me 1-2 months to schedule my first appointment.). They slotted me in for an hour long appointment (a requirement for the first appointment) so that they can really get to know me and my wellness needs. Plus, they said I’d get a chance to get to meet my care team. A care team? What’s that? I’ll let you know after my appointment, but looking at their team I’d say it includes physicians together with health and wellness coaches.

The idea of a team of people thinking about my and my family’s wellness is intriguing. Although, I’ll admit that this wasn’t the biggest reason I chose to sign up with Turntable Health. It was part of the reason, but I was also excited by the idea of unlimited primary care. With unlimited primary care, it opens the door to things like text messages or eVisits with your doctor since they’re truly interested in your wellness and not churning another office visit to get paid.

With a family of 4 kids, there are dozens of times where my wife and I debate whether an office visit is needed. Every parent knows the debate. Am I just being paranoid or are they really sick? Is that rash something that needs to be treated right away or should I give it some time? Final answer: Let’s just take them in, because I don’t want it to be something bad and then I feel like I’m an awful parent because I chose not to take them in. I’m hopeful that with Turntable Health we can alleviate those fears since we don’t have to pay for the visit and we can start with an online visit which saves us time. That’s extremely compelling to me.

I can already say that my experience has been different. After scheduling my first appointment, I got the usual email confirming my appointment, offering directions to the office, and inviting me to fill out an “Online Health Assessment.” I thought it was cool that they were asking me to fill out those lengthy health history forms electronically before the visit. Turns out I was wrong. It was a survey style assessment of my health and wellness. They asked questions about my mental and physical health. They asked about my diet and exercise. They even asked about my quality of life. There weren’t any questions about my neck issue or the pain in my hand, let alone my allergies or past medical history. I wonder if they’ll do that when I get to the office. Plus, I’ll be interested to see what questions they ask me about that true wellness assessment.

Like I said, this appointment should be interesting. To be honest, I feel like I’m learning a new healthcare system. I know what’s appropriate and how the regular doctors office works. Here I’m not sure what’s right or wrong. Take for example the list of health and wellness classes Turntable Health offers with their membership. What other primary care office offers Tai Chi, Hot Hula and Meditation courses? I might even have to start doing yoga. Why not? It’s free. Although, what a different approach to Wellness.

There you go. There’s part 1 of my introduction into a new model for primary care. How will it go? We will see. How will they handle the fact that I’m a picky eater and that doesn’t jive well with many of their perspectives on Wellness? Will they really care about my wellness enough to reach out to me beyond appointments? How will my family and I react to this outreach? Will we stonewall them or will we embrace the increased interaction? It will be a fun journey and I hope you’ll enjoy me sharing it with you.

All in all, it does feel like they’re trying to restore humanity to healthcare. We’ll see how much we like humanity.


Can 10 successful entrepreneurs come up with solutions to 10 of healthcare’s most “wicked” problems in 10 days?

That’s the question Denver’s Tom Higley started asking himself three years ago. Tom, a successful entrepreneur himself and tireless Colorado startup advocate, is the brainchild and chief organizer of an event, dubbed 10.10.10, happening right now in Denver that aims to learn what’s possible.

In a first of it’s kind event, 10 entrepreneurs have been brought together to create products and companies to solve 10 of health care’s wicked problems. Day 10 is today Thursday, Feb. 26th, where we’ll find out what things the CEOs will be working on in the months to come.

Think of it as an executive-level healthcare startup hackathon that lasts 10 days. If it works, it’s going to be taken on the road and into other industries such as food, water, energy and education. With 80% of outcomes linked to things such as nutrition and education, I suspect some of these future events may have an impact on health care as well!

To be sure, coming up with solutions to such problems on short order, in an area where even Apple is apparently struggling to innovate, may seem like a tall order to many on the front lines of digital health, but the expectations are appropriately muted. Higley will measure success by having at least a few solid, fundable companies in the next nine to 18 months.

Perhaps an even bigger story is the dedicated community of people are working to make Colorado a major player in digital health, with 10.10.10 as a showcase. The event and the entrepreneurs are supported by over 100 volunteers and as well as the Colorado Health Foundation, Kaiser, and many others. Bryan Sivak, the U.S. Department of Health and Human Services’ chief technology officer and entrepreneur-in-residence, sent a video in support of the event that was played at the kickoff last week.

There’s also a distrinctly consumer-centric perspective on solutions here as well. Esther Dyson, VC Brad Feld and SomaLogic CEO Larry Gold discussed as much yesterday on a panel, challenging the CEOs to come up with products and business models related to health, not health care, and providing access to data for consumer. If someone’s a patient, it’s often too late for intervention, according to Dyson.

You might want to keep Colorado on your map if you are thinking of starting a digital health company. A new state-of-the-art digital health campus called Stride, set to open in the coming year, will focus on creating a hub of digital health companies. Several major players in health care are rumored to be setting up a presence (more on this in the months to come). Places like Stride, events like 10.10.10, and the dedicated community that supports them, along with success stories like iTriage, are starting to put Colorado on the digital health map.

A cornerstone to the environment I see growing is the willingness of pitch in and help. Local VC Brad Feld talks about that helpful ethos of the Boulder startup community in his book “Startup Communities,” and it seems to have caught on among the digital health people throughout the front range.

Each element of the 10.10.10 event has a “coopetition” aspect to it, even the problems. Individuals and organizations pitched in and submitted problems and the final list was selected based value, difficulty and market opportunity.

The event so far

The first public-facing event was the kickoff where the problems and entrepreneurs were announced. The wicked 10 problems will be familiar to many in involved in digital health and certainly reflect the new realities of non-Fee-for Service (nFFS), quality-based care, public health and a few oldies but goodies:

The 10 Wicked Health Problems are:

  • Alzheimer’s
  • Childhood Obesity
  • Patient Engagement
  • Antibiotic Resistance
  • End of Life Care
  • Pandemic Weapons and Bioterrorism
  • Patient and Data Matching
  • Health Guide Maps
  • Health Data
  • Patient Mobility and Independence

Depending on how you categorize, the wicked problems are pretty evenly divided between public health, patient-empowerment, health IT, and science-focused. Now matter how you organize them, they are big, wicked and broad. It will be interesting to see how the entrepreneurs hone them down to problems to areas that are manageable.

At the midway point event, February 20, the entrepreneurs seemed to be leaning toward some solutions, but no decisions had been made. We’ll have to find out on Thursday where things are headed, I’ll tweet-report back this Thursday, so follow #101010health to find out more.

I hope the midway panel offered some insight to where things are headed. There was an excellent panel with Kaiser’s Dr. Jandel Allen-Davis, SomaLogic (Proteomics company) CEO Larry Gold and Peter Sheahan of ChangeLabs. The dynamic was great, had some great one-liners and made a few things pretty clear. I hope the 10 entrepreneurs, who were sitting in the front row during the session, use some of these takeaways as a guide:

  1. New payment models are happening, we need to reallocate that money to behavior change.
  2. People will be in charge of their health more and more, people need the power to make better decisions.
  3. Longitudinal tracking of everything will happen, but how?
  4. We need to balance security and access of all this info.
  5. There’s still too much harm that can come from the lack of security on health data.
  6. We understand what drives sickness, but not what drives health. How do we move upstream in predicting (beyond stepping on a scale?).
  7. It’s the interaction, not the visit.
  8. Make the healthy choice the easy choice.
  9. Bricks and mortar care will change, but coexist in new ways with the digital.
  10. Many of the changes needed in our health care system are social, not rational.

Peter Sheahan related the story of a meeting where a fresh-faced twenty-something told the Joint Chiefs of the U.S. military that social media would help foment geopolitical unrest. Of course, they snickered and dismissed him out of hand. This was six months before the Arab Spring.

That story makes me hope that we have some of those kinds of thinkers at 10.10.10. I wonder who will be laughed at, but keeps on building, and is eventually proven right in health care? Will it be one of these?

Craig Misrach

Founder and CEO of medical device company Freedom Meditech.

Cheryl Kellond

Co-founder and CEO of Bia Sport, a sports watch company.

Joy Randels

Seasoned executive with a long string of successful companies and an IPO.

Monique Giggy

Monique has started and grown several companies, including Swing by Swing Golf.

Lizelle van Vuuren, Denver, Colorado

Founder and CEO of marketing company Effectively.

Kelly O’Neill Dwight, Denver, Colorado

Principal consultant of KMD Consulting Services.

Zackary Lewis

Founder of Liquid Compass, a radio streaming company.

Lincoln Powers, Billings, Montana

CEO and chief data architect of Rocky Mountain Technology Group.

Best wishes to all to fix some of these wicked problems! It won’t be easy, but we’re rooting for you! Looking forward to tonight to see where things are headed!

Categories: News and Views , All

Many hospitals are now in severe financial difficulty, particularly smaller ones (see: Some Hospitals Experiencing Financial Distress and Even Bankruptcy). A recent blog note by Robert Pearl posted on the KevinMD blog discussed the financial challenges being experienced by small hospitals and one way to provide higher quality care to patients admitted to small, rural hospitals (see: Why rural hospitals are fighting a losing battle). Below is an excerpt from it:

Over the past five years, more than 40 rural facilities have closed their doors due to lack of funding. And because the majority of their funds come fromMedicare and Medicaid...,many rural hospitals may be fighting a losing battle. Understandably, small-town residents fear hospital closures or downsizing may leave them vulnerable when serious illness strikes. But the reality is patients in rural communities often don’t receive optimal care from their local hospitals. In fact, critical access hospitals in rural areas experienced increased death rates from 2002 to 2010 while mortality rates fell in other hospitals.....Fundamental to [the] Hill-Burton [Act] was the belief that residents of rural and low-population areas were best served by local community hospitals, no matter how small....[A]dvancements in medical practice further exploit the differences between America’s leading hospitals and the kind of care available to many of the 60 million people living in rural areas. The truth is many hospitals serving low-population areas don’t have the patient volume or specialists to manage the breadth of complex medical conditions they encounter today....What if rural facilities were used for the kind of routine care and simple procedures that generalist physicians and nurses can safely provide while designating regional hospitals for more complex, specialty care? With today’s video technology, a remote specialist can immediately evaluate a patient and initiate care prior to transport, minimizing delays in treatment. After preliminary testing and stabilization, patients could be safely transported to an operating room in a regional hospital for treatment mere minutes after arrival....But overall, more patients will die in sub-optimal hospitals than during transport to state-of-the-art facilities with the best doctors and nurses.If our goal is to save more lives, we as a country should invest in 21st century technology, communication, and transportation....

Small hospitals are not going to disappear because they are the major employers in many smaller towns. Perhaps Congress will come up with some new subsidy programs to offset the decreased reimbursement from Medicare and Medicaid. However, I am generally in agreement with the arguments made by Pearl. For patients with complex problems, it stands to reason that the care delivered in small rural hospitals will often not be equivalent to that delivered in regional referral centers with medical specialists on their staffs. The question here then reduces to what is the best way to ameliorate this problem without undercutting the mission of the smaller hospitals. I agree with the above statement by Pearl: After preliminary testing and stabilization, patients could be safely transported to an operating room in a regional hospital for treatment mere minutes after arrival. I also agree with the idea of creating telemedicine links between smaller hospitals and regional centers to assist the admitting physicians, when necessary, in the initial diagnosis of patients and their stabilization. Perhaps federal programs are necessary to deploy the necessary technology for telemedicine in small hospitals and put financial incentives in place to so that the regional centers are willing to participate eagerly in such relationships. However, It's not clear to me how the healthcare scenario outlined by Pearl will protect the small rural hospitals from impending bankruptcy.

Budget Night was on Tuesday 13th May, 2014 and it is still not finalised by any means.Both major health and education changes as well as pension changes are still stuck and it seems we have only 4 sitting weeks in Parliament before the next Budget..Thus with the 2014 Budget still not passed we are seeing submissions regarding the 2015 Budget.As early warning it looks like the 2016 Budget is handed down Tuesday 12th , May 2015. -----Other articles this week.General Budget Issues.http://www.thebull.com.au/premium/a/52139-is-australia-spending-over-$100m-a-day-more-than-collected-in-revenue.htmlIs Australia spending over $100m a day more than collected in revenue?By Expert Panel | 16.02.2015By Miranda Stewart, Australian National University“At the moment, we are spending over $100 million a day more than we’re collecting in revenue. Now that’s unsustainable, particularly given we’re spending nearly $40 million a day on the interest on the debt that we have.” – Treasurer Joe Hockey,...

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

February 25,2015


Every once in a while I come across a piece of healthcare prose that I have to share, but there’s no good way to share it in pieces. I found that once in The Old Man and the Doctor Fable. It’s a must read if you haven’t read it.

I recently had another such example shared with me called “Please Choose One“. This one took me a second to really get into it, but about a quarter of the way through, I couldn’t stop reading and had to figure out how it ended. I’m sure that many physicians will feel the heartache shared in this short story. Thank you Philip Allen Green, MD for sharing. If you haven’t gone and read it, go read it…we’ll be back here once you’re done.

Obviously, the story is told in an exaggerated worst case scenario fashion. Although, to me that’s what illustrates the point so well. The lesson I took from the story is that we can’t take the human out of healthcare. Technology should help us offer more humanity to patients as opposed to less. Furthermore, we’re at risk for doing the opposite.

What’s your takeaway? I’d love to hear your thoughts on the story.

Hopeless! David. Late Update. Sen Di Natale asked some e-health questions 3 hours late. All of them were parried saying Government still had no clue what it was doing and what was happening. D.

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All
This was released a few days ago:http://ahha.asn.au/system/files/docs/publications/ahha_pre-budget_submission_2015-16.pdfThe section on E-Health is on page 7 of the 8 page submission:Commonwealth Leadership on System IntegrationThe AHHA acknowledges the Commonwealth Government’s continued support for the national implementation of ehealth tools and resources as holding immense potential to support high quality and consistent care, as well as supporting a number of efficiencies and reduction of waste.The benefit and value of the use of standardised use of electronic health records are well documented: better information sharing and communication between healthcare providers and between patient and provider; reduced duplication or over servicing; more efficient and more appropriate treatment; responds to needs of both clinicians and consumers by being portable and transferrable.Electronic health resources also stand to better support prescribing and referrals for tests and other...

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

February 24,2015

Here is the planned programme for the day. http://www.aph.gov.au/~/media/02%20Parliamentary%20Business/25%20Senate%20Estimates/add1415/ca.pdf Here is the link to watch live: http://www.aph.gov.au/News_and_Events/Watch_Parliament Go to Community Affairs Committee. Enjoy! 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

When we start purchasing our EHR, many times we don’t spend enough time thinking about what happens when we reach the end of life for the software we’re purchasing. I was particularly reminded of this when writing my post about the legacy EHR ticking time bombs. During our EHR or other healthcare IT software purchase, we don’t think about 5, 10, 15 years down the road when we might want to switch systems. What happens at the end of a system’s life is not our concern during an EHR purchase, but it should be.

A lot of people like to talk about EHR data portability. This is a very important subject when you’re looking to sunset an old system. However, if you haven’t put the right items in your EHR contract, it becomes a major issue for you to get that data out of the EHR. If you haven’t read the section on EHR contracts in my now somewhat dated EMR selection e-Book, take some time to read it over and check out your EHR contract.

When you can’t get the data out of your EHR, then you’re stuck in a situation that I described in my legacy EHR ticking time bomb post. You limp your legacy EHR system along and have issues with updates, fear the lost of the system completely, and much more. It’s just an ugly situation.

It’s nice to think that an EHR system will just work forever, but technology changes. It’s just the reality of life. I’m interested to see if the concept of an EHR vendor neutral archive will really take off. That would be one major way to combat this. However, I think many are afraid of this option because it’s tough to preserve the granular data elements in the EHR. Plus, it takes a forward thinking CIO to be able to make the investment in it. Although I’ve met some that are doing just this.

What has your organization done to prepare for the day that you’ll sunset your EHR or other healthcare IT systems? Is this a concern for you? Or are you like some CIOs who figure that it will be someone else’s problem?


The folks who brought us the Pebble Watch are at it again, today announcing the new Pebble Time, a
"Color e-paper smart watch with up to 7 days of battery and a new timeline interface that highlights what's important in your day," on Kickstarter. Features include:
  • We're announcing a new watch called Pebble Time with a new timeline interface.
  • Pebble Time features a new (64) color e-paper display and microphone for responding to notifications.
  • No compromises on what you love about Pebble: up to 7 days of battery life, water resistance and customizability.
  • Pebble Time is fully compatible with all 6,500+ existing Pebble apps and watchfaces.
  • Three colors available exclusively on Kickstarter. Pebble Time starts shipping in May.
  • Extra special engraving for our original Kickstarter backers who support us again ♥♥♥
The first thing we notice is, of course, the color screen. Nice touch, but it is not a touch screen. The Time is still button-driven. It does have a microphone built in to allow some level of voice control or response (although for iOS, this is so far limited to Gmail notifications, but no doubt this will improve. The presence of the tiny hole for the microphone renders the Time water resistant, but not water proof like its elder siblings.

The OS is redone with WebOS underpinnings. It's nice that the now defunct revamped Palm platform has landed somewhere useful.

It's a little cartoonish, but it should be useful, customizable, and still run all the old Pebble apps (and I suppose watch faces too.)
As with all Pebble software, we’ve built an open platform. You can allow apps and developers to add ‘pins’ to your timeline, so you can keep track of things like upcoming events, sports, weather, traffic, travel plans, pizza specials and more.

The Pebble operating system has been re-imagined with a new visual style. While all existing Pebble apps will still work great, we’re inviting developers to upgrade their apps to support color. More details coming soon!
Had you been on the stick, you could have had one of the first 10,000 watches for $159, but they went fast. Pebble has raised $4 Million within hours (minutes?) of the Time's debut. You can still get in at $179 if you act fast. The retail price will be $199.

So why haven't I jumped on this? Two words...Apple Watch. In some ways, this is an apples and oranges (pun intended) comparison. The cheapest Apple Watch will be the aluminum sports version, at about $350, or so the pundits say. The stainless steel model will be $500, and the Gold Elite Apple Fan Boy edition will be $5,000.  But the AW is a whole 'nother animal. Its build quality is likely to be a step beyond the Pebble's, the functionality will be far greater, at least for iPhone owners, the screen will be better and touchable, there will be heart rate sensors (maybe not active initially), and so on. On the other hand, the Pebble Time will be cheaper and supposedly will go 7 days between charges. The Apple Watch apparently will barely make it through the day with moderate use.

I love my original Pebble, which works very well within its parameters. The Time will most likely do so as well. I have high hopes for the Apple Watch, which should be in my hands sometime in April, just before the Time ships. Time will tell, eh?
For as long as I can remember there’s been a great debate in health IT—build or buy? Every few years the pendulum seems to swing more to one side or the other which totally defies the laws of physics in the real world. Today that pendulum is showing signs...(read more)
Source: HealthBlog
My good friend Mike Cannavo, the One and Only PACSMan, called me this morning, quite concerned with something he saw on my blog. No, he's used to the juvenile writing and other foolishness rampant on these pages. But when the PACSMan brought up the blog this morning, he saw this:

Funny, because when I opened the page, I got this:

If you didn't already know, many blogs on Google's Blogger/Blogspot platform use AdSense, which adds a little interest to the process, if you know what I mean.

AdSense is a free, simple way to earn money by displaying targeted ads next to your online content. With AdSense, you can show relevant and engaging ads to your site visitors and even customize the look and feel of ads to match your website.
Watch the video to find out why over two million publishers of all sizes are using AdSense.

Every time you click an ad, I get a fraction of a cent. And I do mean a fraction. In the 10 years this blog has been up and running, I think I've made about $200.00 or so. But it is Google that determines which ads run on the page, based on YOUR browser's cookies. In other words, if you've looked at Dell, or RamSoft, you'll be seeing their ad on an AdSense site.

The AdSense ads thus DO NOT REPRESENT AN ENDORSEMENT OF ANY KIND. If this should reflect on my credibility, meager though it is, I'll turn off the AdSense and you can all put a penny in the mail for my retirement-home-Jello fund instead.

Make sense?

On January 21, the Office of the National Coordinator for Health IT announced that Michael James McCoy, MD, would be the department’s Chief Health Information Officer, a newly created position. According to the announcement, Dr. McCoy will serve as the lead clinical subject matter expert on interoperability, and he has a background perfectly tailored to the task with experience both as a practicing physician and as a leader at the IHE for more than a decade.

Thanks to Dr. McCoy for answering the following questions about the new position and his vision for a learning health system.

Q. First, congratulations on the new appointment with the ONC. You previously practiced medicine and held various leadership positions in the private sector, what attracted you to working with the ONC and what vision do you hope to bring to the department as the industry moves into stage 3 of Meaningful Use?

Dr. Michael James McCoy

Dr. Michael James McCoy

ONC is at a crossroads, coming through a period where significant funding was applied to incentivize the adoption and use of basic electronic health information technology to one where the information can flow to help achieve better care, smarter spending of health care dollars, and healthier people. Now we need to make sure that the infrastructure we have established through the supports created in the HITECH Act can provide returns, with data and analytics capabilities that progress us, as a nation, toward a Learning Health System.

I had the good fortune to be in the right place at the right time to be able to join ONC and the great team of people here to further the goals of improving health, health care, and reducing costs of health care delivery with a person-centric view. Dr. Karen DeSalvo, the National Coordinator for Health IT – my boss – continues to be supportive about the importance of health information technology as the tool to support achieving better health (not as an end unto itself).

I hope that my experience as a practicing clinician with early EMR use in the office, as someone with vendor and implementation experiences, and with system-level knowledge of the challenges for adoption and utilization of the data available, can provide a balanced perspective across ONC.  There are many offices within ONC that have huge impacts on policies, procedures, rules, and regulations – way more than I realized before joining the team here!  There is significant coordination required between the various teams, and Dr. DeSalvo has been working to ensure the views are balanced with senior clinical and legal/legislative perspectives applied.

My vision is that I may be impactful in advancing the notion of person-centric health, and in some small way, help influence the direction that our advancement to a Learning Health System takes. I fully embrace a person-centric concept, and think announced initiatives, including Precision Medicine, will continue taking our nation’s health system down that path.

Q. Karen DeSalvo was quoted as saying you would serve as the ‘lead clinical subject matter expert on interoperability.’ This brings to mind the inclusion of patient-generated health data into the medical record. How do you think the big questions about responsibility for the PGHD (e.g., Is the physician legally responsible to monitor the data? Are patients responsible for accuracy of reported data? etc.) will be resolved? 

The subject of patient-generated health data (PGHD) has many complexities, but in reality, some of the biggest questions relate to similar concerns expressed by clinicians in reviewing “data dumps” from Transitions of Care (TOC) documents, or receiving old records from other physicians. Those concerns relate to the (receiving) physician missing some critical data element in the old record (whether paper or electronic) and their liability as a result of missing that information. There have been lawsuits on this with paper records, and now with electronic records, there is even more data (potentially) for a clinician (or attorney) to review. Whether the data comes from another EHR or from PGHD, there is some obligation for the clinician to review the information received. To what extent and how much data validation must occur (the trust or provenance of the data source) are not yet defined clearly. The legal requirements, the ethical requirements, and the practical requirements for that “minimum level of review” have not been fully established, nor has a consensus view been achieved on what is “right.” ONC is certainly not, in my view, the arbiter of such, though it could, through outreach and coordination and/or through its advisory committees, convene such discussions.

To me, the concerns, about PGHD misses the bigger picture: individuals are now beginning to drive their own health care decisions in a big, and growing exponentially bigger, way. If physicians do not choose to engage with the increased consumer demands, they may find themselves increasingly marginalized in the care delivery system.

This presents opportunities for developers and other technically savvy entrepreneurs to look at the challenge of filtering signals from the noise.  Everyone is busy these days; finding the important e-mail amongst all the other e-mails and spam received is a great thing. Physicians want the same thing from the PGHD received, and from all of the other interactions with their health information technology (rules and alerts that make sense).  Usability, and good (actionable) information, not just data or noise.

Q. A person-centered health system seems to make perfect sense when it’s talked about at the water cooler, yet I sense there is a large chasm that exists between the goings ons in the health care system and the majority of patients in the U.S. How can we be sure that patients really want to be engaged with the health care system?

Not every “patient” wants to be engaged. That is the reality. Sometimes it is exactly those patients, though, that need to be engaged.

However, looking at the opportunity from a different perspective, the way to a better, healthier country is to engage people before they become patients. Witness the growth of wearable devices, connected to the Internet of Things. The FTC report forecasts 25 billion devices communicating over the network this year and 50 billion by 2020.

Further, assuming it is just a patient that wants to engage is another fallacy. Many of us have roles as caregivers, whether for spouses, children, or parents.  Many of us live remotely from the person receiving care. Having access to be able to assist in understanding the care received, ensuring good communications with care providers, and being actively and proactively engaged is possible only through application of health information technology.

There are so many opportunities to improve the relationships between people (whether a patient, caregiver, or healthy individual) and clinicians (in hospital settings, offices, long-term care settings), and technology can help. Many physicians still seem to view patients coming in with externally garnered information (“Dr. Google”) as problematic, instead of as interested and engaged in their health.

The whole care delivery system is in the midst of transformation (even disruption), and embracing and adopting the change is a better approach than becoming obsolete.

Q. As a former board member, you obviously have a lot of interest in IHE’s activities. Where you surprised there was no mention or talk about IHE in the most recent JASON report? What role do you think IHE will play as HL7 FHIR progresses?

The November 2014 JASON report did not reference IHE, but I don’t find that too surprising given the constituency of the advising body. As in many other circumstances, one approach may be favored by those in office at one time and less so by subsequent office holders. IHE references and use was quite prominent in the HITSP days, less so until recently. One may note that in the 2015 Interoperability Standards Advisory draft, IHE is mentioned multiple times, with XDR, XDS, PIX/PDQ, XCA, XCPD, CSD, and HPD all called out.

There are many technically savvy people (aka “geeks”) that work in and with both HL7 and IHE, and harmonization and collaboration between the two groups can only help the overall advancement of health information technology. Perhaps in my simplistic (? naive ?) way, I view the constructs as HL7 and others (SNOMED, LOINC, RXNORM) providing the “ingredients” to IHE’s recipe (e.g., IHE PCC’s APS, LDS for obstetrics) on utilizing in a meaningful way the constituent parts. Much as a cake recipe calls for sugar, eggs, and flour as ingredients, the “how much sugar,” “how to mix,” “how long to bake and at what temperature,” etc. define the end product (the cake). Many different cake recipes exist, just as many different use cases for health data exists….

Q. What do you hope the health care system will look like in 5 years? 

In 5 years, I hope we are well on our way to the Learning Health System, with little or no thought required to get my health data into or out of any part of the care delivery system I am interacting with. I want to be able to take my personally derived data (from exercise on my bicycle or from monitoring my weight with my WiFi-connected scale) and have it available for those with whom I wish to share. I want to be in a health care system that is focused on wellness and general health as much as it has been focused on episodic care and illness.

The draft Interoperability Roadmap (open to public comment until April 3rd) provides the proper vision towards a Learning Health System that will achieve those goals. It may be an aggressive timeline to some. It certainly is reflective that ONC cannot carry the burden alone. Public, private, state, and federal cooperation and collaboration is essential to achieving success. Our nation’s health depends on it. I think it is the most worthy goal one could have as a health care professional. I certainly am proud to be associated with the dedicated and brilliant team here at ONC working to achieve the goal!

Special thanks to Peter Ashkenaz and Brett Coughlin from the ONC for their help facilitating this post.  

Categories: News and Views , All

Some very interesting studies are now staring to emerge using DNA analysis to study the presence and distribution of bacteria in cities like New York. One such study revealed the presence of marine bacteria in a NYC subway station, probably as a result of previous flooding due to superstorm Sandy (see: Post-Sandy NYC Subway Brims with Unknown Microbes). Below is an excerpt from the article:

Researchers identified nearly 1,700 species of bacteria, viruses and eukaryotes to create a “metagenomic” map of the city. One cluster of points on this grid offered a reminder of exactly how inundated and overwhelmed the city was more than two years ago when Superstorm Sandy hit. Nearly half of the mapped DNA came from as-yet undocumented organisms, highlighting how much remains unknown to science about the microbial world around us. The results are detailed in ,,,[a recent study]. ....The most commonly identified DNA in the sample came from bacteria. And although strains of the causative agents of anthrax and bubonic plague surfaced, the vast majority of species identified were harmless....[The author of the study] says these dangerous DNA snippets occurred only at trace levels, so they could have been fragments that other bacteria picked up through horizontal gene transfer or even have come from dead organisms. Most of the bacteria identified are types that placidly thrive on our skin and are of no concern ....But researchers found one of the [subway] stations was not like the others. The South Ferry station in Lower Manhattan had the most unique profile of bacteria in the system, and still resembled a marine environment. When the storm surge from Hurricane Sandy hit the city in 2012, the station filled with about 57 million liters of water that rose to 25 meters deep....The researchers isolated 10 bacterial species that were only found at South Ferry. Among these were Shewanella frigidimarina, which has been found in the North Sea, and Flavobacterium, which can harm certain species of fish. The unique bacteria are usually found in cold, marine environments, so the researchers wondered if Sandy's storm water dragged them in. 

Here's another quote that makes reference to this same microbiology DNA study (see: Big Data and Bacteria: Mapping the New York Subway’s DNA):

The big-data project, the first genetic profile of a metropolitan transit system, is in many ways “a mirror of the people themselves who ride the subway,” said Dr. Mason, a geneticist at the Weill Cornell Medical College. It is also a revealing glimpse into the future of public health. Across the country, researchers are combining microbiology, genomics and population genetics on a massive scale to identify the micro-organisms in the buildings and confined spaces of entire cities.

For me, an interesting aspects of this study is the suggestion that marine organisms might be able to thrive in a "dry" NYC subway station unless the DNA detected is merely residual from dead organisms or related to horizontal gene transfer to other bacteria. If, in fact, these marine bacteria are growing in the South Ferry subway station, one wonders if there are any possible adverse health consequences. However, I suppose that most New Yorkers would consider bacterial growth as one of the lesser threats encountered in subway stations.

This web site was pointed out to me last week:http://www.albertanetcare.ca/default.htmHere is the description from the home page:Welcome to Alberta NetcareAlberta Netcare is the name for all the projects related to the provincial Electronic Health Record (EHR) — a secure and confidential electronic system of Alberta patients' health information. This website has resources for the Alberta public, Alberta health care providers, and people outside of Alberta who are interested in learning more about this innovative initiative. Please read the section below "How to Use this Website" to find information that will be most relevant to you.”The web site is interestingly dated 1995-2015. So this has been underway for 20 years or so. Before going further some basics.Alberta is a province of Canada with a population of a little over 4 million.Here is some background to the Health System from Wikipedia:“Health careAlberta provides a publicly funded health care system, Alberta Health...

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

February 23,2015


I pretty regularly take a look at various healthcare IT whitepapers to glean insights into what’s happening in the industry and what advice vendors are offering healthcare organizations. I’ve been keeping a special eye on the changing reimbursement model and move to value based care and so I was interested in this whitepaper titled “How to Win with Value-based Care: Developing Your Practice’s EHR Strategy.”

The whitepaper starts with a dive into some of the changing care and reimbursement models that are emerging in healthcare. Then they offer this 4 step “Winning Strategy” for being ready for these changes:
Step 1: Assess your current situation
Step 2: Develop a customized VBC Plan that’s right for your practice
Step 3: Determine IT solution needs
Step 4: Implementation

In many ways, this 4 step plan could be applied to any project. Of course, the whitepaper dives into a lot more detail for each step. Although, I was struck by step 3. It takes for granted that value based reimbursement will require an IT solution. This whitepaper comes from a healthcare IT company with some value based IT product offerings so you have to question whether IT will be at the core of a practice’s value based care strategy or not.

As I think about the future of coordinated care and value based reimbursement, I think it’s more than fair to say that technology will be at the center of these initiatives. Value based care requires data to prove the quality of the care you’re providing. Certainly you could try and collect some of this data on paper, but does anyone think this is reasonable?

Try identifying all overweight patients in your patient population using paper chats. I can see in my mind’s eye an army of medical records professionals sifting through stacks of paper charts. It’s not a pretty solution and it’s fraught with error. That’s one query on an EHR system.

One of the biggest elements of value based reimbursement will be communication with patients. Can we build that real time communication on the back of snail mail? It sounds almost silly talking about it. Of course we’re going to use mobile devices, secure messages, and even secure video communication. We still have A LOT of work to do in this regard, but it’s the future.

Of course technology is going to be at the core of value based reimbursement. It’s the only way to accomplish what we’re striving to accomplish. The next question is: will the EHR make this possible or are we going to need something new and more advanced?

February 20,2015


Healthcare IT and EHR security is a really important topic right now. Many organizations have started to spend time and resources on this problem after a series of healthcare and non-healthcare breaches. The Anthem breach being the most recent. Overall, this is a great thing for the industry since I think there’s more that could be done in every organization to shore up the privacy and security of patient health data.

In a recent conversation I had with Mike Semel, we talked about some of the challenges associated with legacy EHR and Healthcare IT systems in offices. Our conversation prompted to me to ask the question of whether these legacy EHR systems are the ticking time bombs of many healthcare organizations.

Think about what happens to many of these legacy EHR systems. They get put in some back office or under someone’s desk or in some nondescript closet where they’re largely forgotten. In many cases there are only 1-2 people who regularly use them and in many cases the word “regularly” equates to accessing it a few times a month. These few people are usually not technically savvy and know very little about IT security and privacy.

Do I need to ask the question about how good the security is on a system for which most people have forgotten?

These forgotten systems often don’t get any software updates to the application or the operating system. The former is an issue, but the later is a major problem. Remember that when updates to an operating system are issued, it’s essentially blasted out to the public that there are issues that a hacker can exploit. If you’re not updating the O/S, then these systems make for easy pickings for hackers.

Forget about great audit log tracking and other more advanced security on these legacy systems. In most cases, organizations are just trying to limp them along until they can decommission them and put them out to pasture. It makes for one massive security hole for most organizations.

Of course, this doesn’t even take into the account the fear that many organizations have that these systems will just give up the ghost and stop working all together. There’s nothing quite like security on a Windows 2000 Server box sitting under someone’s desk just waiting for it to die. Hopefully those hard drives and other mechanical elements don’t stop before the data’s end of life requirements.

These legacy systems aren’t pretty and likely present a massive HIPAA privacy and security hole in many organizations. If you don’t have a good handle on your legacy systems, now might be a good time to take a look. Better to do it now than to deal with it after a HIPAA breach or HIPAA audit.


The Medical Group Management Association has filled the leadership void created when Susan Turney, M.D., left in July, hiring Halee S. Fischer-Wright, M.D., as its new president and CEO. She will start March 23.

According to Englewood, Colo.-based MGMA, Fischer-Wright, a longtime physician executive,  is CMO of St. Anthony North Health Campus, a Centura Health System facility in Westminster, Colo. She previously was president of Rose Medical Group, a large, Denver-based management services organization. Fischer-Wright also was one of three authors of  Tribal Leadership: Leveraging Natural Groups to Build a Thriving Organization, a 2011 book that spent time on the New York Times bestseller list.

“Dr. Fischer-Wright’s unique expertise and experience from working in both clinical and administrative roles will be critical in helping MGMA members prepare for value based payments and leverage the full clinical and operational power of their practices to enhance patient care in their practices and position them for this success,” MGMA board Chair Debra J. Wiggs said in a press release.


February 19,2015


AuntMinnie.com reports an FDA recall of about a zillion GE MRI's and other brands with GE components (well, actually, it's only 13,000 of them):
The U.S. Food and Drug Administration (FDA) has ordered a recall of thousands of MRI scanners manufactured by GE Healthcare to correct a problem that could "result in life-threatening injuries" if magnet shutdown modules are disconnected, according to an FDA notice.

In the notice, dated February 18, the FDA announced that it has ordered a class I device recall of all GE MRI scanners using superconducting magnets. The recall covers some 33 brand names of scanners and thousands of systems distributed throughout the world, manufactured from 1985 to today.

The notice describes the problem as pertaining to the systems' magnet rundown units (MRUs), which are designed to initiate a controlled quench and turn off the magnetic field in the event of certain problems with the scanner, such as a ferromagnetic object introduced into the MRI suite. Such shutdowns are only intended for extreme emergencies and can put an MRI magnet out of commission for a week or more and cost up to $30,000 to replace lost helium, according to the website MRIQuestions.com.

In GE's case, a scanner's magnetic rundown unit may not actually be connected to the scanner, according to the FDA recall notice. In an emergency, a disconnected MRU "could delay removal of a ferrous object from the magnet, potentially resulting in life-threatening injuries," the notice said.
You can find the FDA notice HERE. You'll have to scroll through thousands of serial numbers to get to the meat of the notice:

Manufacturer Reason
for Recall
At certain sites, the MRU may not be connected to the magnet. In emergency situations, a disconnected MRU could delay removal of a ferrous object from the magnet, potentially resulting in life-threatening injuries. The MRU must be connected to the magnet at all times.
FDA Determined
Cause 2
TRAINING: Employee Error
ActionGE Healthcare sent an "Urgent Medical Device Correction" letter GEHC Ref# 60876 dated January 6, 2015 to affected consignees. The letter was addressed to Hospital Administrators / Risk Managers, Radiology Department Managers, & Radiologists. The letter described the Safety Issue, Safety Instructions, Affected Product Details, Product Correction & Contact Information. Customers were instructed to do the following: As a preventative measure, confirm that MRU is connected to the magnet by performing the following four step test on the MRU.

1. Verify the green CHARGER POWER LED is lit.

2. Depress and hold the TEST BATTERY switch for 15 seconds. The green BATTERY TEST LED should light and remain lit while the TEST BATTERY switch is depressed.

3. Place the TEST HEATER toggle switch in the A position. The green HEATER TEST LED should light. If it does not light, depress TEST HEATER LED switch to verify that the LED is functioning.

4. Place the TEST HEATER toggle switch in the B position. Green HEATER TEST LED should light. If it does not light, depress TEST HEATER LED switch to verify that the LED is functioning.

If the MRU test does not perform as described in each of the 4 steps above, GEHC strongly recommends that you stop using the system, and immediately call your GEHC representative. Customers with questions may contact their local service representative. For questions regarding this recall call 262-513-4122.
Quantity in Commerce12,968 (5,708 US, 7,260 OUS).
Oops. Did I see employee error listed as the problem? AuntMinnie's Brian Casey notes:
The company said it learned of the problem after discovering that some MRI scanners in India had been modified by service personnel or by equipment users to disable the magnet rundown unit. In addition to alerting customers to the problem, GE noted that the red magnet rundown button should only be pressed in an emergency situation.
Now why, one might ask, would anyone want to disable the MRU? Inquiring minds want to know. And did we really need the reminder that the big red button that says, "PRESS IN CASE OF EMERGENCY" should be pressed only in an emergency? Perhaps that tells us something about GE's opinion of its customers.

Mobile MRI services take note...business awaits!


My sources around the world are telling me this issue is the fault of GE and NOT the Indian fellows they were blaming. Here's one report:
It (the MRU) was never connected or properly installed. We can't disconnect it. So it was a GE issue. Big problem though.
More to come...This is pretty scary.


Well, that didn’t last long. My full-time job ended abruptly today, less than three weeks after I started. So here I am back to freelancing and blogging. Any leads would be appreciated. Meantime, stay tuned for new content.



I have blogged previously about tests and imaging procedures relating to the diagnosis of Alzheimer's disease (see: Early Detection of Alzheimer's Disease: Mutations of Three Genes StudiedUsing Altered Metabolic Pathways to Diagnose Alzheimers DiseaseAlzheimer's Amyloid Tangle Theory Will Be Tested with Merck Drug Trial). I don't think that any test or imaging procedure to date has proven to be foolproof. However, a recent article raised the important question of whether one would want to even know the result if such a test were available (see: New Test Claims It Can Tell If You Will Develop Alzheimer's... But Do You Want To Know?). Below is an excerpt from the article:

The dichotomy of those who want to know and those who do not is separated by a deep chasm in beliefs, and could forever alter the way individuals, families and wealth managers prepare for disease, as well as how insurers and care providers pay for and provide care. While genetic tests are presently able to determine about 4,000 diseases and disorders, the breakthrough of predicting Alzheimer’s disease could vastly change the behaviors and costs to society, actually bending the cost curve health experts so often talk about as necessary for economic stability....In January, Amarantus reported positive top-line results of its LymPro Test...for Alzheimer’s disease. The Company also entered into an exclusive option agreement with Georgetown University (GU) to commercialize sets of blood-based biomarkers for Alzheimer’s disease....But how will individuals react? How about the care provider and insurance markets? When there is presently no cure, it is expected that individuals and families will be torn on the decision to test.  In contrast, it seems inevitable that employers, health officials and insurers will want to know the future demands, needs and composition of their populations....While LymPro is not ready for the shelves of CVS or Walgreen ’s, it may not be long before in clinic and in home testing is available to consumers. Without a cure or highly effective symptomatic treatments to go hand-in-hand with the blood test, the risk and reward of such a test will certainly take a toll on individuals, families, health care markets and communities.

Here's a brief summary of the LymPro test mentioned in this excerpt copied from the Amarantus web page:

The Lymphocyte Proliferation Test (LymPro Test) is a diagnostic blood test that measures the ability of peripheral blood lymphocytes to withstand an external stimulation inducing them to enter the cell cycle. It is hypothesized that certain diseases are the result of a compromised cellular machinery that leads to abhorrent cell cycle re-entry by neurons.The inventive step for LymPro that makes a unique asset involves using peripheral blood lymphocytes (PBLs) as a surrogate for neuronal cell function, suggesting a common immune-based relationship between PBLs and neurons in the brain.

There is no single answer as to whether one would want to know if he or she was destined to develop Alzheimer's disease with no effective treatment for the condition. Some individuals with a strong predisposition to planning might benefit from such information, particularly if the test would offer some time prediction for the onset of the disease. On the other hand, such bad news could destroy another person psychologically. What is clear, however, is that the precise identification of those who have, or will develop the disease, is a requirement for the development of clinical trials for drugs that ameliorate or cure the disease. In fact, the availability of such clinical trials could provide an incentive for individuals to seek the test because only those who test positively would be admitted as a subject to them.

February 18,2015


I'm a little late with this entry, but...

I have a friend who works for Fovia, a supplier of rendering software and more. I've blogged about them in the past, and I've always been impressed with their stuff.  

Anyway, here are some of their latest renderings of PET/CT images:

Think how much easier it would be to explain to the surgeons (or the patients) where the lesion actually lies if we could show them something like this! Should have been Image of the Year, in my book, but then the RSNA appears to be reading a different book altogether...

February 17,2015


oliver“Please, sir, I want some more.” – Oliver Twist

In this super-sized world, we tend to believe that “more” is better than “less.” I personally believe more trumps less in many areas:

  • All things being equal, I’d rather have more money than less. Most providers seem to agree, which is likely one reason for today’s hot market for applications and services that maximize reimbursements and help providers qualify for more financial incentives.
  • I am always wishing for more time. Providers, vendors, and payors are seemingly obsessed with wanting more time. Why else would we see so much lobbying for extending Meaningful Use deadlines or the transition to ICD-10?
  • The world would be a better place with more dark chocolate.

Of course more isn’t always better. Quite often – especially in the health IT world – less is actually “more.” Consider the following:

  • MGMA recently asked CMS to consolidate its reporting programs and eliminate its use of multiple Web portals for Medicare Part B reporting. Fewer portals means fewer registrations, user names, passwords, and the like, as well as less confusion as to which portal to access for what task. Fewer portals equates to increased efficiencies and fewer administrative hassles.
  • As EMR adoption has grown, so too has the length of a typical chart note. Clinical documentation is no longer just a means for tracking a patient’s condition. Instead the chart note has become the primary tool for meeting billing requirements and justifying reimbursement. The chart note has fallen victim to “note bloat;” that is, with EMRs it’s too easy for users to paste in non-essential data, making it difficult to narrow in on the most critical elements. The American College of Physicians and other professional organizations are now calling for the redesign of EMR-generated documentation to make it is more concise and reflective of the information gather to develop an impression, diagnostic and/or treatment plan, and recommended follow-up.
  • Healthcare generates a wealth of patient data that can be analyzed during the care process, or on a larger scale to measure everything from internal quality metrics to population health trends for predictive analytics. Some may argue that more data is better, but a case can also be made that all data is not equally good/relevant/of value. When it comes to big data, perhaps more data is okay as long as we have plenty of “spam” filters to eliminate the irrelevant.
  • In terms of hardware technology, what’s not to love about less? We embrace devices that are increasingly smaller; we seek components with produce less noise and use less energy; and we’re spending less capital as more applications migrate to the cloud.
  • And of course in the general healthcare world, stakeholders often criticize the over-use of healthcare services in U.S., which not only wastes dollars and resources, but may harm the health of patients, according to a Health Affairs report. Ten to 30 percent of total healthcare spending is considered unnecessary and the waste includes everything from overprescribed antibiotics, excess testing, and unnecessary surgeries.

Oliver Twist and chocoholics may disagree, but sometimes less can be the best way to go.

Categories: News and Views , All

Our next HealthIMPACT CIO Summit will take place next Friday, February 27th, 2015, at the Union League Club in New York. Our conversation kicks off in the morning with Ed Marx, SVP & CIO at Texas Health Resources and 2014 IW Healthcare CIO of the Year, and Michael Restuccia, VP & CIO at University of Pennsylvania Health System. I will be interviewing Ed and Michael together on stage and we’ll focus on how to establish a process that will embed successful innovation into the culture of an organization. We’ll start by asking a provocative question:

Is “digital health innovation” overrated banter that we’re required to embrace for political correctness or is actionable innovation in complex health systems really possible?


Doing more with less has always been an IT leadership challenge. Population health management, value-based care, patient engagement, connecting patients and physicians, transitioning to ICD-10, data analytics for better clinical decision making, the list goes on and it gets longer every year. Just keeping up with changing requirements is tough enough but asking CIOs for disruptive innovation on top of it all may be too much.  How will CIOs handle the increasing demands for reliable and safe IT systems but also be at the forefront of “bleeding edge” technology simultaneously? I’m hoping that Ed and Michael will help us understand how to:

  • Set the right priorities and manage demands for speed, change, and innovation while resources decrease or stay the same
  • Increase the rationality and the accountability of priority setting for technology adoption to avoiding overbuying and under-utilizing
  • Strike the right balance between proposed and planned projects
  • Figure out how to evaluate which innovation projects are working and which need to be eliminated
  • Create leadership strategies that replace a culture of blame with a culture of collaborative innovation
  • Support fast and agile delivery of new ideas but retain patient safety, maintain systems reliability, and data security
  • Work with Start-Ups and other disruptive innovators to not disrupt but measurably improve care and workflow processes


Space is filling up fast so if you haven’t registered for HealthIMPACT East already, please register today.

The post Is digital health innovation overrated? appeared first on The Healthcare IT Guy & Digital Health Nexus.


I have posted a number of previous notes about 23andMe, a company that offers consumer-oriented genomic testing on the web (see, for example: 23andMe Database Sheds Light on Genetic Aspects of Racial Mixing23andMe Requests FDA Clearance for DNA Saliva TestingPfizer and 23andMe Collaborate to Study Inflammatory Bowel Disease). There has been substantial criticism of the company revolving around questions about the quality of the testing, whether the company was acting inappropriately by providing medical advice to customers, and whether it was acting unethically by selling the genetic information obtained from its customers specimens. A recent Forbes article summarized these questions about 23andMe and posed the salient question of whether its customers were suckers or empowered consumers (see: Are 23andMe Customers Suckers Or Empowered Consumers?). Below is an excerpt from the article:

The mock shock we’re seeing is based on the assumption that 23andMe customers have been hoodwinked into contributing their data to these partnerships....But is that really the case? I’m a 23andMe customer and have received regular communications from the company detailing how to opt into or out of research. There’s another way to look at this: that customers know what they’re doing and see this as a way to make a difference. Most of us know that drug company pipelines are weak, and that it costs far too much to develop new therapeutics. It’s in everyone’s interest to find faster, cheaper ways to develop more effective drugs. If access to data at 23andMe helps accomplish that, we all win. Sure, there are different models to consider. For example, I’d like to see an approach that financially rewards people who contribute their data to research that leads to a viable new drug. The fact that Pfizer signed on for a second deal could be a validation of the idea that mining massive amounts of aggregated data can lead to better drug candidates. One of the most expensive elements in developing a new medication is the clinical trial process. It costs a fortune to locate the right people, convince them to participate, account for all those who stop partway through, and of course monitor drug reactions throughout. There’s also the physical toll for all the participants who discover first-hand the side effects of a new drug. 23andMe can’t solve the clinical trial problem, but its data may help drug companies better target their trials toward patients whose genetics make them more likely to do well on a drug, or less likely to suffer adverse reactions. That kind of targeting could save money, put fewer people at risk, get drugs to market faster, and ensure new medications are given to people most likely to benefit from them.

I agree with the author of this article. In my opinion, the company has been transparent about what it was doing with the genomic data derived from submitted cell samples. I personally have obtained important genetic information about myself from the test that I probably would not have otherwise been aware of. I am sure that other companies will copy the 23andMe business model and sell genetic information to drug companies to facilitate drug research and clinical trials. The biggest mistake that the company has made thus far, in my opinion, is underestimating the the power of the FDA. I do suspect that some of the criticism of 23andMe comes from physicians and scientists who are not comfortable with the idea of consumers ordering lab tests, particularly genetic testing for themselves. I don't agree with this viewpoint.

There is a growing movement among consumers of taking more ownership of their own health and healthcare. An important facet of this movement will be to enable them to order lab tests by and for themselves, including molecular and genomic testing. In short and with reference to the headline of the Forbes article, I think that such testing opportunities will lead to more empowered healthcare consumers. The article also broadly endorses the sale of genome data to foster research as long as the consumers submitting their personal specimens are made aware of the sale of such anonymized data.


The folks from HP Matter digital magazine wanted to know where I thought digital health startups, product innovators, and venture capital investors should be pointing their attention in 2015. These are some of my technology and healthcare predictions:

  1. CMS’s request for information (RFI) on new primary care models bears innovative fruit.
  2. Interoperability will move beyond talk and into sustainable business models and real technology. The healthcare ecosystem should be able to create lasting patient benefits.
  3. Risk management, compliance, and cybersecurity technologies will become important as we migrate from paper native to digital native data.
  4. EHR innovation starts to move beyond Meaningful Use (MU) by embracing the idea that MU is a floor for minimal functionality, not a ceiling for maximum value. Some of these innovations will be tied to CMS’s need for newer care models:
    • Mobile functionality in EHRs to help change the doctor/patient relationship to one that is more than transactional in nature
    • Tech for increased comprehensiveness of, and patient continuity with, primary care
    • Tech to support small PCP practices in transforming to advanced primary care
    • Advanced primary care within accountable care organizations, along with multi-payer participation and performance measurement that is meaningful to beneficiaries and clinicians
    • Analytics and solutions to track performance measurement that is meaningful to beneficiaries and clinicians,
  5. Digital health investors start to realize how hard it is for health IT companies to make money without interoperability and integration. Innovators begin moving away from small simple mobile apps, standalone solutions, and non-workflow based systems into larger services-focused enterprise tech. The new tech will understand that minimizing disruptions across workflow steps in the continuum of care is a key goal.
  6. ACOs and value based healthcare starts to affect the marketplace because solutions providers finally focus on beneficiary management and attributed populations instead of general population health.
  7. Data in healthcare (especially genomics and bioinformatics) has always been big. But, new “Big Data” tools start to offer instant analytics and predictive models that affect real patient care instead of being focused on research alone.

The January HP Matter issue has some pretty useful information. You can Register for HP Matter for a chance to win an HP SlateBook x2, an Ultrabook™ and a tablet in one. Weekly drawings will be conducted throughout January and February.

This post brought to you by HP Matter. The content and opinions expressed below are that of The Healthcare IT Guy.

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The post 7 digital health innovations and investments for 2015 appeared first on The Healthcare IT Guy & Digital Health Nexus.

February 16,2015

IT professionals, healthcare executives, and clinicians in hospitals, health systems and clinics around the world are expressing great interest in moving more of their organizations’ IT applications and services to the public cloud. The concept of having...(read more)
Source: HealthBlog

Assessing the magnitude and significance of cyber threats has at least two important purposes. One is to determine the extent of measures that have been or should be taken to respond to or counter the threat. This is part of the rational deployment of resources across the multiple risks that we face, whether cyber or otherwise. In this regard it is simply not possible or necessary to respond to all risks with equal vigor. A second purpose can be to communicate threat significance to or among interested parties. For such communication there is a tendency to reduce complex, multifaceted issues to a simple broad summary word, e.g., the threat level is “Guarded”. Such simplicity is possibly attractive but not necessarily meaningful with regard to what to do with the information communicated.

Of interest here is how those issuing threat assessments are making their determinations. One approach is quasi mathematical in which components of a threat are “scored”, and then those scores combined in some way, with the net score then indicating something of supposed significance. Those of us who have used methods such as those in ISO14971 are familiar with scoring severity and probability, and then presenting these in a two dimensional grid which is then divided into some number of risk zones (often 3). A “risk score” is also often determined by multiplying the severity score by the probability score to get the risk score, although there is no theoretical basis for such a multiplication. None-the-less, with a multiplication scheme additional factors can also be considered, scored and also multiplied. The best known of these additional factors is detectability, especially when risk assessment is applied to manufacturing and inspection is meant to ideally find and eliminate bad product from the production stream, thereby reducing the risk of a manufacturing defect reaching the end user. My colleague and I have discussed the limitations of these kinds of fake mathematical calculations here and here. Limitations do not mean that a method should not be used. Instead it means that it should be used knowingly and with caution.

In the cybersecurity space a different kind of math has emerged, as used for example by the National Health Information Sharing and Analysis Center (NH-ISAC). Here four factors are combined by addition and subtraction using the relationship Severity= (Criticality + Lethality) – (System Countermeasures + Network Countermeasures). Each of these four factors has a 1-5 scale with word descriptions of each, e.g., a criticality of 3 is “Less critical application servers” while a lethality of 3 is “No known exploit exists; Attacker could gain root or administrator privileges; Attacker could commit degradation of service.” As far as I have been able to determine there is no theoretical basis for or validation of linearly adding and subtracting the four individual scores, nor is there a basis for each factor having the same 1-5 scale. In addition the use of the same scale for each factor introduces a false symmetry, e.g., a Criticality of 4 with a Lethality of 2 has the same effect as a Criticality of 2 with a Lethality of 4. There is also a false relativity with respect to, for example, 4 being logically perceived as twice as bad as 2.

The conversion of the calculated number into a particular threat level also appears to be more-or-less arbitrary. In NH-ISAC there are 5 threat levels: Low, Guarded, Elevated, High, and Severe (with corresponding color codes Green, Blue, Yellow, Orange, Red). The score range for these 5 threat levels is distributed with the intervals being 3, 2, 3, 2 and 2, which also seems arbitrary. This scheme also results in many different combinations of the four factors leading to the same overall rating. In addition the end result has high sensitivity to the inherent uncertainty in the individual scores. Furthermore there is an inherent limitation in knowing just the end result, e.g., Guarded, which is that it is not possible to work backwards to find out what contributed to that level. For example in a particular instance was it high criticality or low protection? Also, it cannot be determined how much taking an action that moves an individual score up or down would help unless the raw score is reported along with the level. How individual Severity scores are combined to produce a global Severity score is not described. In fact as used by NH-ISAC, it is not even possible to publicly determine what actual threat or threats they have considered in arriving at their overall threat level. If you don’t even know the particular threat it is not possible to respond, even if a response was appropriate. Given that this methodology has no available documentation we also don’t know anything about inter-rater variability, i.e., to what degree would two independent raters arrive at the same scoring.

A different group with an online presence in threat rating at first offered me the following explanation of their methodology (from an email): “The determination is somewhat more subjective, how the rubric is calculated has not been published to my knowledge. We essentially get together online and have a discussion about the current issue.” This methodology clearly is not transparent. Subsequent to my inquiry they added to their website a linear combination scoring system that has at least some of the same limitations as the one discussed above.

Another characteristic of third party threat assessment is that those doing the assessing are not those who have to respond to the threat. Nor do they have to rank the cybersecurity threat in comparison to other threats to patient and system safety that have nothing to do cybersecurity. Yes, such threats do still exist. This can lead to a Chicken Little mentality in which those enmeshed in their own arena of doom come to believe that their perceived doom is the only doom, or at least a much worse doom than other people’s doom. Moreover it leads to the self aggrandizement of their own domain, and attempted self propagation of their importance. In this regard the announcement of the  recent collaboration between two cybersecurity threat rankers included the assertion that, “This landmark partnership will enhance health sector cyber security by leveraging the strengths of…” the participants and “…will facilitate improved  situational awareness information sharing.” all before they had done anything. How grand!

Health related cybersecurity is no doubt an issue that has to be treated seriously, but this must be done in the context of all the other issues that challenge the healthcare enterprise and the safety of patients. In this context we should not confuse potential vulnerabilities with actionable risk, nor confuse any risk with a critical risk. In this regard it is important to remember that safety is the absence of unreasonable risk, not the absence of risk.

William Hyman is Professor Emeritus of the Department of Biomedical Engineering at Texas A&M University. He now lives New York City where he continues his professional activities.


Categories: All , MedTech and Devices

February 15,2015

A short story by Phillip Allen Green. Read this and be afraid. It describes my worst IT nightmares..
Please choose one:
The three words blink in front of me on the computer screen.
Please choose one:
Patient is-

Male     Female 
I click FEMALE.
I watch as the auto-template feature fills in the paragraph for me based on my choices.
Patient #879302045
Patient is: 38-year-old female status post motor vehicle accident. Please acknowledge you have reviewed her allergiesmedications, and past medical history.
I click YES.
Have you counseled her about smoking cessation?
I click NO.
A little animated icon of a doctor pops up on the screen. His mouth begins to move as if speaking. A speech bubble from a comic strip appears next to it.
“Tip of the day: smoking cessation is important for both the patient’s health and part of a complete billing record.” 
The animated doctor smiles and swings his stethoscope like a lasso.
A new screen appears.
Please choose one:
The patient’s current emotional state is best described as-
☐ Distraught     Calm      Agitated
I turn away from the computer to look at the patient. She lies curled in a ball on her side. Her bare feet stick out below the sheets halfway off the gurney. I notice she has a turquoise blue toe ring. She stares straight ahead. She plays with her patient ID band, twisting it round and round with her other hand. Makeup is smeared around small brown eyes. She stares blankly at the wall behind me. I clear my throat. She doesn’t blink. I clear it louder. Still nothing.
I look back to the computer. The same screen is still there.
Please choose one:
The patient’s current emotional state is best described as- 
☐ Distraught     Calm      Agitated
I turn back around.
Blonde hair is matted to the right side of her face where tears have dried it to her skin. A thick strand of it hangs across her eyes and I wonder if it annoys her. I watch as tears reform in her eyes and run sideways across her face. A teardrop starts to grow on the side of her cheek. More tears are added until finally it falls from her face onto her tear soaked pillow.
Her chest rises and falls at a rapid pace. She is breathing fast, almost panting. It is a raspy sound. I bet if she spoke right now her voice would sound raw, the kind of scratchy raw that comes after too much screaming. But she doesn’t speak. She just lies there breathing with a thousand yard stare fixed to her face.
The computer dings.
Please choose one.
The computer takes me to a new screen.
Please choose one:
Patient’s primary reason for being distraught-
Emotional     Physical     Other
The patient starts moaning. I look over. A guttural sound that is part wail, part cry spills out of her just loud enough for me to hear.
That selection triggers a new screen for me with new choices:
Please choose one:
What is the reason for patient’s emotional problem?
Intoxication   ☐Psychiatric   ☐Neurologic
Hmm, I look at her trying to decide which to choose. She is in a hospital gown. Her clothes were cut off with the trauma shears when she came in. She still smells like gasoline and blood and burnt plastic smoke. It burns my nose sitting this close to her and makes my eyes water.
There’s dried blood mixed with car oil and dirt on her chest. There is a lot of it. It covers her shoulders and the top of her breasts like a red patchy shawl, yet she is not injured. She has been examined and x-rayed and CAT scanned from head to toe. Her body is fine.
The computer dings again impatiently, prompting me to choose one.
Please choose one:
What is the reason for patient’s emotional problem?
Intoxication   ☐Psychiatric   ☐Neurologic
I click the Next arrow at the bottom of the screen to try and advance the page without choosing one.
My mouse circles the screen hesitantly. I guess I will click… PSYCHIATRIC. In a way emotions are psychiatric, I tell myself.
Choosing psychiatric has opened a new screen.
The patient shifts on the bed. A glimmer on her head, reflecting the fluorescent lights above, attracts my attention. I lean in closer. There are shards of broken up windshield glass scattered throughout her hair. Some are brown from dirt from where she lay on the ground, some are stuck to her head from blood, and some are scattered on the sheet below her. The shards twinkle on the bed like little stars.
I frown, the nurse was supposed to clean her up. I wheel backwards on my doctor stool across the trauma room to the door. I lean my head out through the curtain.
I look around. I spot the patient’s nurse. She is sitting on the other side of the ER, working at a computer. I know she is trying to enter data from the patient’s visit to get her charting done. Well, I think, maybe someone else can help us.
I scan the ER. There are doctors and nurses everywhere down here, yet every single one that I see sits at a computer with their eyes chained to the screens and a scowl on their faces while they click and type, click and type. I bet the hospital could burn down around them and they wouldn’t notice.
“Hey!” I yell.
No one even looks up. The clicking and typing continue.
An old man standing in the doorway of another patient room makes eye contact with me. He scowls as he surveys our ER. He shakes his head in disgust. I blush and duck back into the room behind the curtain.
The computer dings twice now, prompting me to hurry up. I remember my patient throughput time is monitored and reported and compared to the national average. A timer has appeared on the bottom of the screen, letting me know that I am four minutes twenty-eight seconds past the average ER doctor throughput time.
The numbers keep climbing. If I spend too much time on one patient, I will get a letter from administration for not meeting my throughput quota. I wheel back up to the computer.
Please choose one:
Because you chose Psychiatric, patient was offered-
Counseling     ☐Medications     ☐Inpatient Care
A sob wracks my patient’s body interrupting me again. She shifts in the bed, leaving clumps of brown dirt crumbling on white sheets. She is absolutely filthy. I wonder how long she lay in that field before someone found her. She still stares at the wall, unresponsive.
I look back at the computer. I didn’t offer her any of these things. Maybe I should lie and click counseling so that I can finish her chart.
I click Next.
YOU MUST CHOOSE ONE pops up again.
Please choose one:
Because you chose Psychiatric, patient was offered-
Counseling    ☐Medications   ☐Inpatient Services
I try alt tab. No luck.
I give up and click COUNSELING.
Another screen.
Please choose one:
Patient responded to counseling with:
Excellent Improvement Some Improvement No Improvement 
The little doctor figure reappears on the screen. He’s holding up his index finger and a light bulb appears over his head as if he’s just had a fantastic idea he can’t wait to share with me.
“Dr. Tom Tip reminds you: Did you try offering a drink of water or a tissue? Surveys show that sometimes it’s the little things that make patients feel better.”
I look over at her. I can’t bring myself to offer her water. Her knuckles are blanched white from the death grip she has on the side rail. She’s mouthing the word NO over and over to herself and shaking her head back and forth. Her eyes are wide with terror and do not see me. The skin of her face is pulled taut with fear.
I know that look. She is seeing the moment. I know she is going to see it again and again for the rest of her life. It will come in nightmares, it will come in dreams, it will come at the worst possible moment of what should be happy occasions, more likely than not it will even come at the moment just before her own death no matter how long she lives. She will never escape it. Sixty-eight minutes ago her brain burned an image into the inside of her skull that she will never be able to unsee.
I click SKIP.
The doctor icon disappears, replaced by text.
Please choose one:
Did you offer the patient water?
Yes     No
I click NO.
The little figure pops up again this time with a stern look on his face and his arms crossed.
“Surveys show patients like it when their doctors offer them water or a tissue. Patient satisfaction scores go up. Try it, you might be surprised.” He uncrosses his arms and holds out a little of glass of water.
For a brief second I imagine punching my fist through the computer screen. It would feel so good to climb the stairs to the top floor of the hospital with the computer stuck on my arm. I imagine spinning in a circle and launching it as hard as I can off the roof of the hospital towards the pavement below. I would give anything to see it smashed and destroyed and ruined, just as it has done to this profession I once loved.
But I know they would just replace it with another computer and just as quickly with another doctor.
I sigh and look around the room.
There is a cup on the counter.
I frown, it is awfully dirty.
I pick it up and turn it over.
A child’s tiny, bloody shoe falls out onto the counter.
The woman cries out, Oh God Oh God Oh God and grabs the child’s shoe before I can pick it up.
She holds it next to her face. She’s sobbing now and starting to scream. Oh God Oh God Oh God Oh God Oh God. She clenches the shoe to her chest. The blood on the shoe matches the blood on her chest.
The computer dings.
“Did you give the patient a cup of water?”
I lie and click YES.
“Good job!” The computer trumpets out a happy horn sound. It’s hard to hear over the patient’s screaming. The little doctor gives me a thumbs up and high fives a hand that appears on the screen next to him.
“Sometimes it’s the little things that make people feel better.” The doctor says.
I click NEXT.
The Patient Disposition Screen loads.
Please choose one:
Where is the patient going after the ER?
Home     ☐Admitted     ☐Transferred
I hover the mouse on the screen for a second, trying to decide.
I click HOME.
Please choose one:
How is the patient doing after your care for her?
Improved      ☐Not Improved     ☐Other
I look at her again.
This time the whole screen flashes. The little doctor is back, hands on his hips. His face is stern as the speech bubble appears next to his head. The letters are in red this time.
“Patients who are NOT improved should NOT be sent home. You clicked Psychiatric as her primary issue. Perhaps some medications would help the Healthcare Consumer. Would you like me to recommend some choices available on the hospital formulary?”
I ponder the question. Is there a drug for this? Something that will make her feel better? Something that doesn’t wear off like, ever?
I click NO.
Are you sure? The computer asks again.
I click YES.
A big red flag now pops up on screen and the computer buzzes like a half time buzzer in a sports game that I have just lost.
A note of this patient encounter has been sent to your Hospital Administrator for chart review of this patient. It is the goal of our healthcare facility to make patients feel better before they are discharged. You have acknowledged that you failed to do so. You will likely receive a lower patient satisfaction score for this.
Please acknowledge.
I click NO.
It flashes again.
Please acknowledge.
I click NO.
Please acknowledge.
I click NO.
A box pops up.
I am sorry, Valued Healthcare Provider, do you not understand the question? Would you like to fill out a service ticket?
Yes   No
Please choose one.
The words blink at me on the screen.
I look over at the patient. She is on her side again, sobbing as she cradles the tiny shoe to her chest. Her eyes are squeezed shut and she’s rocking back and forth so hard the whole gurney is shaking.
I look back at the computer.
Please choose one.
I look back at my patient.
Please choose one.
Suddenly I get it. I choose.
I reach down and unplug the computer. The screen goes black.
Without the noise of the computer fan whirring, the room is suddenly silent- save for her quiet sobs.
A strange feeling comes over me, one I almost forgot existed after so many years.
I remember who I am and why I am here.
I stand up and take a deep breath. I step towards the patient and begin the long and tedious process of gently picking out the shards of bloody glass stuck throughout her hair. As I start to work she opens her eyes and blinks.
She sees me.
The terror filling them fades just a tiny bit.
For once the computer stays quiet.
I pick through the strands of her hair. The three words blink in my mind over and over.
Please choose one…
Please choose one…
Please choose one…

©Philip Allen Green

February 13,2015


After a prolonged and contentious debate, CMS has approved CT scans for lung cancer screening for high risk medicare patients (see: Medicare approves lung cancer screening coverage). Here is the link to the decision summary from CMS and below is an excerpt from an article on this topic:

The Centers for Medicare and Medicaid Services have finalized coverage guidelines for lung cancer screening with CT scans for people at high-risk of developing lung cancer. Coverage goes into effect immediately.....The CMS decision stems from the National Lung Screening Trial, a large-scale clinical trial funded by the National Cancer Institute. It found that among 53,000 heavy smokers at high risk of lung cancer, CT screening demonstrated a 20 percent reduction in lung cancer deaths. CMS, which provides health care benefits to those 65 and older through Medicare, will cover annual lung screenings for people age 55-77 who have smoked at least 30 pack years and are either current smokers or quit within the last 15 years. Patients will need a written order from their doctor for screening and must undergo counseling that emphasizes smoking cessation. The decision includes requirements for qualifying radiologists and screening facilities to ensure quality and safety. It also creates a lung screening registry.

I think that this debate has resulted in the right decision that may even save the government some money by detecting early cases of lung cancer amenable to treatment. It makes sense that the CT lung screening was restricted to only high-risk older patients. Although the smoking rate is declining precipitously among younger people (see: Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965–2011), it will take decades for the carcinogenic effects of tobacco to "wash out" of the general population. Screening of populations with CT scans was debated fiercely because of the cost of the procedure and uncertainty about its effectiveness. Some of these same arguments have arisen in relationship to molecular and genomic screening but this will get sorted out in time.

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