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Attachment Ridicule

2012-05-10T22:03:00.001-07:00

May 2012: Attachment Parenting

May 2022: Attachment Ridicule

Are you
the joke in your 7^th grade class?

Meaningful Inertia Too

2012-05-08T17:03:00.001-07:00

Should meaningful use objectives serve as the basal behavior for digital health information or serve as minimal criteria for governmental payments?

AMA Comments on Meaningful Use Stage 2 EHR Proposal (PDF):

The AMA is supportive of widespread adoption and meaningful use of EHRs by physicians, but the cumbersome proposed criteria will make successful physician participation extremely difficult…[d]ue to physicians' limited ability to exchange data with other health care partners[.] [M]any of the proposed Stage 2 measures will require extensive manual data entry…not an efficient way of practicing medicine or improving quality care outcomes for patients.

Physicians should not have to meet all 20 measures plus clinical quality measure reporting to prove that they are a meaningful user of a certified EHR. Allowing physicians to opt-out of a certain number of measures (e.g., three or more) is the type of flexibility needed in the meaningful use program that would encourage more physician participation and increase participation

[C]linical summaries [for patients] should [be] three business days and the threshold requirement should be 20 (not 50) percent. The measure should also be based on unique patients seen during the EHR reporting period, and not based on every office visit to minimize reporting burdens. In addition, a physician should have the flexibility to include only the information that the physician believes to be relevant for the summary.

Principles of patient access in Directed Exchange:

Paraphrasing

In the digital world, 36 hours is unreasonable. It means that humans continue to be involved in tasks that can be perfectly-performed by computers without errors. Thirty-six hours means that doctors, nurses and hospital administrators think in paper, view the patient as an unequal data partner, and leaves the patient blind to the data at the only time it really matters—now. Thirty-six hours old data can only be analyzed as a post-mortem and is a short-term solution while rethinking information flow and the notions of "inside"and "outside" the hospital.

Most Physicians Were Eligible For Federal Incentives In 2011, But Few Had EHR Systems That Met Meaningful-Use Criteria:

[A] 2011 nationally representative survey of office-based physicians [] found that 91 percent of physicians were eligible for Medicare or Medicaid meaningful-use incentives. About half of all physicians intended to apply[—]only 11 percent both intended to apply for the incentives and had electronic health record systems with the capabilities to support even two-thirds of the stage 1 core objectives required for meaningful use. [W]idespread gaps in readiness throughout the states illustrate the challenges physicians face in meeting the federal schedule for the incentive programs.

Physicians Ready for Stage 1 Objectives 2011

Modified from Health Affairs^†

Physicians Intending to Apply for Meaningful Use Incentives 2011

Modified from Health Affairs^†

Physicians Exchanging Electronic Clinical Summaries 2011

Modified from Health Affairs^†

^† Most Physicians Were Eligible For Federal Incentives In 2011, But Few Had EHR Systems That Met Meaningful-Use Criteria

Professional/Ethical Parity

2012-05-07T23:31:00.001-07:00

Nutshell: common sense, social media = public media, and you are always a licensed professional. A "license" means a voltional act and a public duty.

FSMB Press Release:

[P]hysicians [] need to be aware of how to maintain the same professional and ethical standards in their online activity as they do in the rest of their practice. Failing to do so can hurt patients and physicians’ careers.

Violations of online professionalism are prevalent among physicians…92 percent of state medical boards in the United States have received reports of violations of online professionalism.

FSMB Policy:

Physicians should not use their professional position, whether online or in person, to develop personal relationships with patients. The appearance of unprofessionalism may lead patients to question a physician’s competency. Physicians should refrain from portraying any unprofessional depictions of themselves on social media and social networking websites.

Candor

Physicians have an obligation to disclose clearly any information (e.g., financial, professional or personal) that could influence patients’ understanding or use of the information, products or services offered on any website offering health care services or information.

Privacy

Physicians have an obligation to prevent unauthorized access to, or use of, patient and personal data and to assure that “de-identified” data cannot be linked back to the user or patient.

Integrity

Information contained on websites should be truthful and not misleading or deceptive. It should be accurate and concise, up-to-date, and easy for patients to understand. Physicians using medical websites should strive to ensure that information provided is, whenever possible, supported by current medical peer-reviewed literature, emanates from a recognized body of scientific and clinical knowledge and conforms to minimal standards of care. It should clearly indicate whether it is based upon scientific studies, expert consensus, professional experience or personal opinion.

New FSMB Policy Addresses Appropriate Use of Social Media by Physicians: Press Release (PDF)
Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice (PDF)
Help! My Shrink Tried To Friend Me
Online Posting of Unprofessional Content by Medical Students

Meaningful Inertia

2012-05-07T21:17:00.001-07:00

Corpus omne perseverare in statu suo quiescendi vel movendi uniformiter in directum,
nisi quatenus a viribus impressis cogitur statum illum mutare.¹

Trotter posits a principle zero:

[S]ome clinicians [and hospitals] will do anything they can to make patient access to their health records impossible or cumbersome.

True in action, but not intent. What's at play here is inertia (Newton's Frist Law)—the installed practices, investments, expenditures, expectations, beliefs, etc. are sufficient to create a true adverse physical inertia. Inertia is not geared to patient access, but to minimally impact the status quo.

Oram commenting on inertia:

[T]he AHA offers no hint that the hospitals spent all this money to put in place new workflows that could improve care. All the money went to EHRs and the minimal training and installation they require. What will it take for hospitals to make the culture changes that reap the potential benefits of EHRs and data transfers? The public needs to start asking tough questions, and the Stage 2 requirements should be robust enough to give these questions a basis.

Meaningful use financial inducements are not about making fundamental changes affecting the state of health information's inertia, but rather all about using (channeling) existing inertia to collect today's carrots and to ward off tomorrow's sticks.

A very long gentle sloop…

Modified from AHA²

Acute Care Non–Federal Hospitals with at least a "Basic" EHR

The stage 2 meaningful use objectives³:

Clinical Decision Support
Drug Formulary Checks
Patient Education
Patient Lists
Advance Directive
Comprehensive List of Allergies
PACS for Imaging Results
Demographics
Vital Signs
Structured Labs
Smoking Status
Bar Coding
Patient Medication Lists
Immunizations
Reportable Labs
Syndromic Surveillance
Patient Problem Lists
Automatically Generated Quality Measures
Care Record Summary
CPOE for Medications
Information Exchange
Patient Portal

The majority of hospitals, as assessed in the fall of 2011, do not meet the stage 2 objectives in whole or part.

Modified from AHA²

Distribution of Hospitals Meeting Stage 2 Objectives in Fall 2011

Modified from AHA²

Share of Hospitals Meeting Stage 2 by Objectives

Larger

The overarching principle with respect to patient access to electronic health record data…should be[] nothing about me without me[;] but the overarching reality is all about me with nothing to see.

Radar: Trotter's Principles of patient access in Directed Exchange
Radar: Oram's The state of health IT according to the American Hospital Association
Nothing about me without me
CHIME stands with AHA, comments to CMS (PDF) and ONC (PDF)

Newton's First Law of Motion (Inertia): Every body persists in its state of being at rest or of moving uniformly straight forward, except insofar as it is compelled to change its state by force impressed. The velocity (inertia, momentum) of a body remains constant unless the body is acted upon by an external force.
AHA Comments on Meaningful Use Proposed Rule (PDF)
Medicare and Medicaid Programs: Electronic Health Record Incentive Program–Stage 2

Sheer Typelessness

2012-05-07T16:21:00.001-07:00

11,515 tweets ≈ 6 tweets/day

5 years
60 months
1,827 days
43,846 hours
2,630,760 minutes
1.578456×10⁸ seconds
2 much

Nothing about me without me

2012-05-07T00:10:00.001-07:00

SPM’s responses to the proposed rules for Meaningful Use Stage 2:

We favor improving the likelihood that patients will access their data by allowing for some automation of the process of accessing and downloading patient data, using existing technologies that protect patient privacy and security.

We also favor immediate patient access to information in the patient’s electronic health record—unless the patient has elected otherwise.

The overarching principle with respect to patient access to electronic health record data running through the entire meaningful use regulation and the health IT standards regulation should be:

“Nothing about me without me.”

Society for Participatory Medicine
Meaningful Use Stage 2
SPM’s open letter to CMS (PDF), to ONC (PDF)

Accreting Scrutiny

2012-05-03T18:00:00.001-07:00

Debt Panels

Accretive Health Annual Report 2010:

The Accretive Health Revenue Cycle Process Structure and Metrics

Payer Relationship Management: People & Technology

The Medical Quack
Colbert Nation
Accretive Health's response, Annual Report 2010 (PDF), Annual Report 2011 (PDF)
Minnesota Attorney General's filing (PDF )
Accretive LLC's portfolio

Beyond "R" is "F"

2012-05-02T17:57:00.001-07:00

Beyond rationing and the duty to avoid waste lies the fiduciary duties—control cost and provide care.

From an Ethics of Rationing to an Ethics of Waste Avoidance

Bioethics has long approached cost containment under the heading of “allocation of scarce resources.” Having thus named the nail, bioethics has whacked away at it with the theoretical hammer of distributive justice. But in the United States, ethical debate is now shifting from rationing to the avoidance of waste.

…

The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too.

…

The two principal ethical arguments for waste avoidance are first, that we should not deprive any patient of useful medical services, even if they're expensive, so long as money is being wasted on useless interventions, and second, that useless tests and treatments cause harm. Treatments that won't help patients can cause complications. Diagnostic tests that won’t help patients produce false positive results that in turn lead to more tests and complications. Primum non nocere becomes the strongest argument for eliminating nonbeneficial medicine.

Beyond the “R Word”? Medicine’s New Frugality

Quietly, Washington policymakers have begun to concede the need to weigh health care’s benefits against its costs if our country is to avert fiscal ruin. That costs must be counted against benefits is common sense in other domains—and among health policy professionals. But it’s anathema in public discussion of medical care. To silence talk of tradeoffs, politicians invoke the “R word”—rationing.

…

Even if we could eventually eliminate that waste, we would merely postpone the reckoning…unless we start saying no to some beneficial care. Eliminating only ineffective care would shift the cost curve down but wouldn't change its slope.

Sharp Dull

2012-05-01T22:29:00.001-07:00

sharp (ὀξύς, oxus) + dull (μωρός, mōros) = oxymoron = trust + advertising

We trust individual(s) and institution(s) based upon a positive history, or a belief in those that have had a positive history. Trust is an historical or surrogate value assessment. Advertising is the inference of value without an historical or surrogate relationship. Brand is about the creation (earning) of trust—surprise, ads in whatever venue won’t fare well.

To what extent do you trust the following forms of advertising?

Modified from Nielsen Global Trust is Advertising Survey, Q3 2011

Global trust-in-advertising-2012

View more documents from ecommercenews

Nielsen

Slideshare

SEO

SMO

Multi-Pin Screen

2012-04-30T23:50:00.001-07:00

Noise to Signal Cartoon

Increased Information, Decreased Cost?

2012-04-30T20:19:00.001-07:00

Argument: HIE access (and use) will help ACOs with the issue of admissions (and readmissions?).

An interesting problem with association in this study—what about the Hawthorne effect? Does the physician change his/her game because “when we know more, we do less”? If the outcome is decreased cost (marker), then is there an implicit assumption that decreased cost tracks improved quality of care?

Another aspect that comes into play is not just the availability of information from an HIE, but is the relevant information from the HIE delivered JIT. The cost may go up if information is not JIT when you factor in that “without information, testing occurs” with longer dwell times in the ED (LOS). Then add in the cost from lost business, where LOS backs up the ED and affects overall throughput (increases LWBS).

The financial impact of health information exchange on emergency department care

Objective. To examine the financial impact health information exchange (HIE) in emergency departments (EDs).

Materials and Methods. …Outcomes studied were…admissions,…laboratory testing, head CT, body CT, ankle radiographs, chest radiographs, and echocardiograms.…

Results. HIE data were accessed in approximately 6.8% of ED visits across 12 EDs studied…[and] was associated with a decrease in hospital admissions…[,] head CT use, body CT use, and laboratory test ordering.

Discussion. Applied only to the study population, HIE access was associated with an annual cost savings of $1.9 million. Net of annual operating costs, HIE access reduced overall costs by $1.07 million. Hospital admission reductions accounted for 97.6% of total cost reductions.

Conclusion. Access to additional clinical data through HIE in emergency department settings is associated with net societal saving.

J Am Med Inform Assoc 2012;19:328-333 doi:10.1136/amiajnl-2011-000394
HIE = health information exchange
ACOs = accountable care organizations
JIT = just–in–time business, 看板
LOS = length of stay
LWBS = left without being seen or without service

NAS

2012-04-30T18:37:00.001-07:00

A significant and increasing problem in the ED! Someone needs to do a study on the association (if not causality) of satisfaction medicine and the rampant rise in prescription narcotic use and subsequent addictions in our society.

Neonatal Abstinence Syndrome and Associated Health Care Expenditures

Context. Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome primarily caused by maternal opiate use. No national estimates are available for the incidence of maternal opiate use at the time of delivery or NAS.

Conclusion. Between 2000 and 2009, a substantial increase in the incidence of NAS and maternal opiate use in the United States was observed, as well as hospital charges related to NAS.

EHR Adoption a Power Law?

2012-04-30T17:41:00.001-07:00

The graphs from the article (infra) would seem to suggest that EHR adoption (either basic or full) is a linear (proportionate) process, where the scaling factor is “α”:

f(x) = αx
adoption = α(time)

But, as with most endeavors—wonder if it is more than a proportionality? The article further suggests that physician payments may suffice—more money (more “α”) and more adoption in a linear manner. If adoption has a power law (non–linear) relationship with time; then what are the factors that affect “κ”? Utility? Ubiquity? Both carry significant inertia (beyond a critical adoption level) that is most likely non–linear.

f(x) = αx ^κ
adoption = α(time)^κ

Physicians In Nonprimary Care and Small Practices And Those Age 55 and Older Lag In Adopting Electronic Health Record Systems
Abstract. [M]ore than half of all office–based physicians were using electronic health record systems, but only about one–third of those physicians had systems with basic features such as the abilities to record information on patient demographics, view laboratory and imaging results, maintain problem lists, compile clinical notes, or manage computerized prescription ordering.…[A]doption of electronic health record systems across geographic regions converged from 2002 through 2011, adoption continued to lag for non–primary care specialists, physicians age fifty–five and older, and physicians in small (1–2 providers) and physician-owned practices.…

US Physicians with EHR Systems

US Physicians with Any EHR System or with a Basic EHR System, by Specialty

US Physicians with Any EHR System or with a Basic EHR System, by Practice Size

US Physicians with Any EHR System or with a Basic EHR System, by Ownership

Wailea & Haleakalā

2012-04-29T15:20:00.001-07:00

Haleakalā, Maui, HI 10,023 ft (3,055 m)

Haleakalā: looking southwest; AutoStitch

Haleakalā: looking northeast; AutoStitch

Ferraro’s, Wailea, Maui, HI: looking west; AutoStitch

Wailea, Maui, HI: looking west; AutoStitch

Saturn alive

2012-04-28T00:26:00.001-07:00

via Scientific American

gtap

2012-03-31T23:24:00.003-07:00

Gmail Tap:

8 bit map

2012-03-31T23:24:00.001-07:00

Google Maps for NES:

Customer Experience

2012-03-30T15:51:00.001-07:00

Blackhawk

2012-03-22T17:43:00.001-07:00

Source: restorationhardware.com on Pinterest

Countercyclone

2012-03-21T17:25:00.001-07:00

Privacy Rights, Right!

2012-02-23T00:17:00.001-08:00

We Can’t Wait: Obama Administration Unveils Blueprint for a “Privacy Bill of Rights” to Protect Consumers Online (PDF):

The Administration’s framework consists of four key elements:

A Consumer Privacy Bill of Rights:

Transparency: Consumers have a right to easily understandable information about privacy and security practices.

Respect for Context: Consumers have a right to expect that organizations will collect, use, and disclose personal data in ways that are consistent with the context in which consumers provide the data.

Security: Consumers have a right to secure and responsible handling of personal data.

Access and Accuracy: Consumers have a right to access and correct personal data in usable formats, in a manner that is appropriate to the sensitivity of the data and the risk of adverse consequences to consumers if the data are inaccurate.

Focused Collection: Consumers have a right to reasonable limits on the personal data that companies collect and retain.

Accountability: Consumers have a right to have personal data handled by companies with appropriate measures in place to assure they adhere to the Consumer Privacy Bill of Rights.

Fostering Multistakeholder Processes to Develop Enforceable Codes of Conduct

Strengthening FTC Enforcement

Improving Global Interoperability

Satisfaction Medicine

2012-02-15T15:32:00.001-08:00

Unintended consequences, predictable consequences? Have we seen the entrenchment of a whole industry (satisfaction medicine) that is both detrimental to health care generally and to the individual specifically?

Opinions will vary on the cost and value of “defensive medicine”—so institutionalized in medicine. We now have the institutionalization of “satisfaction medicine”—the cost and value are? I’ll bet, when scrutinized, that satisfaction medicine will dwarf both the cost and the “perceived” value of defensive medicine. US Healthcare probably deserves its own entry (if not chapter(s)) under the topic of “unintended consequences” (and “unintended incentivizations”). Seems silly and trivial, but Numeroff really has nailed what has happened so well —“if” is never followed by a singular “then”. We find ourselves trapped by the superficially vetted, that now is so entrenched.

The Cost of Satisfaction

Background. Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined.

Conclusion. In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

Arch Internal Medicine

Wikipenia

2012-01-18T15:42:00.001-08:00

Learn more.

Irish Face[] Data

2011-12-21T17:10:00.001-08:00

The Irish data protection commissioner has recommended widespread changes to improve privacy on Facebook—particularly significant because Facebook Ireland [has] responsibility for all non–US and Canadian data.

Suggested changes:

a mechanism for users to make informed choices about how their information is used and shared on the site, including in relation to third party apps;
increased transparency and controls over how personal data is used for advertising purposes;
transparency and control for users via the provision of all personal data held to them on request and as part of their everyday interaction with the site;
the deletion of information held on users and non-users via what are known as social plug-ins, and more generally the deletion of data held from user interactions with the site much sooner than at present;
an update to its data use policy/privacy policy to take account of recommendations as to where the information provided to users could be further improved;
an additional form of notification for users in relation to facial recognition/"tag suggest" that, it is considered, will ensure Facebook Ireland is meeting best practice in this area from an Irish law perspective;
an enhanced ability for users to control tagging and posting on other user profiles; and
an enhanced ability for users to control their addition to groups by friends.

Private Notes and Privacy

2011-12-21T17:09:00.001-08:00

Inviting Patients to Read Their Doctors' Notes: Patients and Doctors Look Ahead:

Doctors: Opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients.

Patients: Expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care.

Understatement: Sharing visit notes has broad implications for quality of care, privacy, and shared accountability.