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Monday, September 24, 2018

The Biden Cancer Initiative

BidenCancer.org

Last Friday Cheryl and I attended the local Biden Cancer Summit, which was held at John Muir Hospital in Concord (where I'd had my SAVR px heart surgery 28 days prior). Local congressman (and cancer survivor) Mark DeSaulnier hosted the event, which was comprised of a panel of clinical and medical business experts, and a panel of cancer survivors, with Q&A sessions following each panel discussion.
The CEO of the Muir Health System, Cal Knight, spoke. I subsequently introduced myself to him, and gave the hospital high praise for my treatment.
Given our long and painful history as family cancer caregivers and my own 2015 experience as a cancer patient, we found it all very interesting, if not exactly news to us. Nicely done.

Joe Biden:


I need to give some thought on how best to support this effort going forward, as I heal up fully.

All lofty, laudable principles. A number of them, however, (1-5 in particular), go to chronically contentious "multi-stakeholder" policy issue areas. I find no detail on the website at this point addressing any of these areas in any substance. There's much drill-down work to be done (say, e.g., seven "White Papers" for starters) if this undertaking is to bear fruit. 

apropos, see also the NIH/NCI "Cancer Moonshot."
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More to come...

Sunday, September 23, 2018

A literal "shitstorm." What of the public health upshot?





Climate Change Comes Home To Roost In North Carolina
Breached swine lagoons. Overflowing coal waste ponds. Sewage in the streets. The hellish aftermath of climate-fueled Hurricane Florence.

FAYETTEVILLE, N.C. — Florence’s rain came down in sheets ― unrelenting, and for days on end.

The water inundated homes, many still boarded up from Hurricane Matthew two years earlier. It swallowed farm operations, killing millions of chickens and turkeys and overflowing open pits full of hog feces. It flooded coal ash ponds, sending the toxic byproduct of burning coal into area waterways. The smell of human waste tainted neighborhoods; in the small town of Benson, 300,000 gallons of raw sewage spilled into the streets.

On Friday, Charlotte-based Duke Energy reported that a dam containing a lake at one of its power plants in Wilmington had been breached by floodwaters, potentially spilling coal ash from a nearby dump into the Cape Fear River…
Ugh.

One immediate question of concern: what proportion of residents in the affected areas have their medical histories contained in EHRs? And, of those, what sub-proportion are housed in remote cloud-based systems largely immune from storm damage (as opposed to local in-house client-server installs in the-now flooded docs' clinics)? In the aftermath of Katrina, untold thousands of medical records were lost forever. One hopes things have materially improved since then.

I'm not finding much recent news about it. Here's one item:
LESSONS FROM FLORENCE: SET UP ADVANCE HIE CONNECTIONS
With proper disaster prep, Health Information Exchanges play key role in transmitting patient data.
Natural disasters, like Hurricane Florence, present challenges to health systems and providers not only in areas directly impacted, but also to those in neighboring regions who treat patients displaced by the catastrophe. One of the greatest issues: access to patient records.

Health Information Exchanges (HIEs), play a critical role in making these records available. But there's a catch. Electronic connections must be set up in advance by HIEs in the impacted areas and in locations where patients may migrate. And, health systems and providers on both sides of the disaster must participate in an HIE and be connected to a data-sharing network for the data transfer to occur.

Because HIEs are a relatively new resource, a closer look behind the scenes of the nation's most recent widescale natural disasters demonstrates the value these organizations offer and provides lessons as health systems prepare for the future…
That's from the only news article I've thus far found on the topic.

THE LARGER, LONGER-TERM THREAT


Ugh. Raw sewage, dead livestock, fish, pets, etc, overflowing pig farms' excrement ponds, breached power plant coal ash lagoons, massive amounts of household and automotive chemicals -- note the chemical sheens evident in most post-hurricane flooding overhead photos...

Hurricane Florence Is a Public Health Emergency, Too
With its hog manure pits, coal waste ponds, and toxic Superfund sites, North Carolina is among the worst places a major cyclone could hit.

 

...“You don’t want hog waste flowing freely for the same reasons you wouldn’t want sewage flowing freely into the river and the house,” Gisler said. Feces is a breeding ground for bacterial pathogens like salmonella and giardia, and exposure via drinking water could cause experience a number of gastrointestinal problems. Exposure via open wounds or other mucous membranes could cause E. coli.

North Carolina has seen this before. During Hurricane Floyd in 1999, the manure lagoons from dozens of hog farms spilled “over thousands of acres of private and public lands and into the watersheds of four rivers that feed the second-largest estuary system in the nation,” according to the environmental news site Coastal Review. The storm’s extreme rainfall also killed more than 20,000 hogs, whose drowned bodies’ were scattered across the coastal landscape. The state legislature passed a moratorium on new manure lagoons after Floyd, but critics say little has been done to reduce the number of them across the state...
The continuing chronic lack of comprehensive, seamless digital health record "interoperability" (my irasible "Interoperabbable") will yet again result in significant friction hampering aggregate longitudinal public health assessments -- of this, and prior natural disasters.

ERRATUM

I am now one full month out of my open heart SAVR px surgery. So far, so good, overall.
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More to come...

Wednesday, September 19, 2018

The "Silver Tsunami" and health care



I need to Photoshop myself onto that bench, first wave baby boomer that I am (born in Feb 1946).
Some good news: my cardiologist told me Friday that it was indeed a viable goal to get me all the way back to my delusional full-court hoops gym rat Jones. I start cardiac PT rehab on October 9th.
The 2018 Health 2.0 Annual Conference just wrapped up in Santa Clara. I find distressingly little mainstream press coverage, via searching Google News. Some stuff is just regurgitated press release copy.


Above, HIMSS CEO Hal Wolf:
Every hospital has to innovate for Silver Tsunami
The aging population is becoming more educated and driving transformational change, Wolf said at Health 2.0.


SANTA CLARA, CALIFORNIA — The worldwide challenge of treating aging populations is driving the healthcare industry toward innovation, according to HIMSS CEO Hal Wolf.

Speaking at the Health 2.0 conference here Monday, Wolf said that in the U.S., 49 percent of healthcare costs are covered by the government, yet as the ‘Silver Tsunami’ continues, that cost is expected to leap to 53 percent. But the problem isn’t just money, it is also the lack of manpower and skilled providers to take care of the aging population. Currently there is a gap of 7 million healthcare professionals, but that gap is only expected to grow, he said.

“That is why purely and simply … every healthcare system in the globe is trying to figure out how they are going to use innovation to take all of this [sic] disparate and disconnected components [and] bring it [sic] back together, so we can deliver care to rising populations, that are going to be sicker,” Wolf said. “That is what is siting behind the rising investment digital health. It is not something that is going to easily burst because the drivers that sit behind it are not the evaluations themselves as much as the socioeconomic drivers.”

Many are looking toward data as a way to solve problems in healthcare, as more and more of it becomes readily available. But data alone isn’t [sic] the solution, Wolf said.

“Data is [sic] fundamentally useless until you turn it into information,” Wolf said. “Until you take the data that is [sic] ones and zeros and categorize it, and put it [sic] into digestible chunks, we do not have the ability to use it [sic] the way we want to. If you think about your own apps or apps you’ve worked with, it is about taking that [sic] data and turning it into information … that information when you do comparative analysis turns itself into knowledge. This is where knowledge management is so important because it creates standards and targets and goals. There is inside knowledge and outside knowledge. Then finally when we apply little bits of data targeted against clinical utilities or capabilities or services that [sic] is what we deliver to the healthcare system.”

Healthcare is often behind on innovation. Wolf said the system is playing catchup to other industries in someways. For example, he said that his dog had a registry at its vet before his son had one at his doctor's. That doesn’t mean healthcare should catch up to old technology — rather, should be looking towards new better innovation like a segmented personalized registry. For example, a patient being treated for breast cancer shouldn’t get a breast screening reminder.

But it isn’t just the healthcare systems that are looking to change. Wolf also stressed that patients are becoming more engaged and informed about their health…
Tangentially related prior post: "Are we 'overcharged' for health care? Will it get even worse?"

Hmmm... "Innovation?"


A fine, relatively quick read. Short easily digested chapters with "accelerator" queries following each one. e.g.,
1. A FUTURE ORIENTATION

“The world makes way for the man who knows where he’s going.” - Ralph Waldo Emerson

I’ve repeatedly seen it—successful people have a future orientation. They may not know exactly how they’re going to get there, but they have a crystal-clear vision of their intended destination. Underlying this vision, storming towards the uber-successful is a three-step framework involving Clarity, Focus, and Execution.

I first learned the power of this trinity by accident. I worked my way through college as an emergency medical technician for a hospital-based ambulance service. I decided to major in respiratory therapy for one simple reason—I wanted to be a member of the flight team aboard Angel One at Arkansas Children’s Hospital. The day I began the professional portion of the respiratory therapy program, I waltzed into the department director at Arkansas Children’s Hospital and declared, “I just began respiratory-therapy school, and when I graduate, I’m going to come here and fly on your helicopter. So, if you’d like to hire me—know you can train me during the next few months, so I’ll be ready when I graduate.”

I didn’t get the job that day. A few months later, after observing me during a clinical rotation, that department director hired me. The day after I graduated, I was a member of the Angel One Flight Team. I spent the next several years living my dream. Fate had another surprise in store for me: another member of that team was my future wife, Lori.

Successful people have clarity on where they are going. They develop a relentless focus on that destination, and they understand how to impeccably execute that plan. Those three keys can make the difference between where you are and where you want to be. Make it happen!

1. A FUTURE ORIENTATION ACCELERATORS
  • What does your ideal future look like in three, five, and/or ten years? Spend the time necessary to develop crystal clarity on that desired future.
  • On what things must you intently focus to fulfill that vision or to arrive at that desired destination?
  • What things must you achieve or accomplish in the next twelve months to take you as far as possible toward that vision or destination?
  • What key actions must you take daily or weekly in order to achieve or accomplish those twelve-month milestones?
Standridge, Dr. Jeff D.. The Innovator's Field Guide: Accelerators for Entrepreneurs, Innovators and Change Agents (Kindle Locations 224-247). Fitting Words. Kindle Edition.
And so forth for 52 topical chapters.

This preface setup is noteworthy:
Innovation in any setting can be daunting. Being an entrepreneur is gut-wrenching, and filling the role of change agent takes a level of energy that most do not feel they possess. When you have the responsibility of being a change agent in your business, organization, or community, the burden of leadership weighs heavily on your shoulders…
…Innovation in any setting can be daunting. Being an entrepreneur is gut-wrenching, and filling the role of change agent takes a level of energy that most do not feel they possess. When you have the responsibility of being a change agent in your business, organization, or community, the burden of leadership weighs heavily on your shoulders… [ibid, Kindle Locations 184-186].
"The burden of leadership." Yeah. More, from the IHI Forum.

Relatedly, I'll reprise something from a December 2017 post of mine.
__

Below, I finished this book. Very good.


Dug it. Although, for a book claiming to have "launched the Lean Startup revolution," there is precisely nothing in it going explicitly to Lean methodology practices. Putting the "customer discovery / customer development" processes ahead of the "product development process," yeah, I get all that (and, charitably, it's foundational to a Lean philosophy, in many ways a direct descendant of Deming). But, no discussion of key topics such as "PDSA," "Value Stream," "Gemba," "Kaizen," "the 5 S's,", "A3," "Fishbone Diagram," etc.

I kept getting a recurrent feeling: "yeah, this is largely good old MBA (albeit PDSA-iterative) SWOT analysis stuff."
__

One thing I find consistently missing from these "innovation / startup" tomes are any substantive methodological discussions regarding old-fashioned scut-work "cost center" organizational functions -- i.e., in Lean "value stream" lingo, the "no-value-add-but-necessary" processes. Standridge at least tangentially makes mention of it in passing:
Entrepreneurs innovate while simultaneously being change agents. If wearing those hats isn’t stressful enough, payrolls and payables have to be met. Entrepreneurs must make certain their customers are served, their employees are paid, and their bills are current, while also ensuring life needs are met. No matter what blows up at work, the kids still must be housed, shuttled to school, fed, clothed, and put to bed… [ibid, Kindle Locations 198-201].
I'd just like to see more detailed and actionable "cost center process management" advice in the current startup literature. Tossing out broad allusions to "Lean," "Agile," "Innovation," (even "Effectuation") etc leaves me still a bit wanting.

I've reflected before on my own distant, haphazard tenure as a startup partner back in Tennessee:

 
Back in the 80's, while working at the International Technology Corporation environmental radiation lab in Oak Ridge, I was a Principal in an "exam cram" A/V business with a professor at UTK who taught private exam prep courses (e.g., SAT, ACT, GRE, LSAT) on the side. We started a company and then produced and marketed a series of 2-hour VHS videos and their accompanying print booklets in my South Knoxville hole-in-the-wall studio.

We bought "targeted" mailing lists (i.e., school guidance departments, libraries, and families with kids in school at the right grade levels) and sent out mass mailing brochures. The rule of thumb in Direct Mail back then was that a 1% return/sale rate was sufficient to be profitable were your costs fully baked in and your retail pricing still competitive.

I was the Managing Partner (Corporate VP/Sec'y-Treasurer/Registered Agent, actually). Producer, Director, Editor, Copywriter, Layout Artist, and Data Entry and UPS Shipping Clerk.

There's gotta be a DSM-V code for that...
Seat-of-the-pants multiple-hats improv management, those days.

Had I not had to miss the 2018 Health 2.0 Conference, I'd certainly been asking these types of questions of the startup atttendees.

UPDATE

A shot from a Twitter post (hashtag #health2con). Probably from a smartphone. There's ever-less point for my schlepping around 20 lbs of DSLR cameras and lenses, given improvements in smartphone optics.

"EMR Evolution: How the Big Players are Changing the Game"

Really would have liked to have seen that one. As noted by MobiHealthNews back in August:
Though doctors likely don’t consider their EHR a cutting-edge technology, the EHR space is actually a front line for change and innovation in healthcare. And that change is happening on a number of different axes: interoperability and open standards, personal health records, and the move into public cloud infrastructure are some of the biggest change narratives.

Microsoft, which provides technology to power many of the major EHR vendors, has a dog in each of those fights, and Microsoft Chief Medical Officer Simon Kos will be one of a handful of presenters on a Health 2.0 panel called “EMR Evolution: How the Big Players are Changing the Game,” along with representatives from Google Cloud, Cerner, and Allscripts…

SEPT 20 UPDATE: AI VC NEWS

Ran across this, mentioned over at Wired. The book is to be released on the 25th.


From the Amazon blurb:
Dr. Kai-Fu Lee—one of the world’s most respected experts on AI and China—reveals that China has suddenly caught up to the US at an astonishingly rapid and unexpected pace.  

In AI Superpowers, Kai-fu Lee argues powerfully that because of these unprecedented developments in AI, dramatic changes will be happening much sooner than many of us expected. Indeed, as the US-Sino AI competition begins to heat up, Lee urges the US and China to both accept and to embrace the great responsibilities that come with significant technological power. Most experts already say that AI will have a devastating impact on blue-collar jobs. But Lee predicts that Chinese and American AI will have a strong impact on white-collar jobs as well. Is universal basic income the solution? In Lee’s opinion, probably not.  But he provides  a clear description of which jobs will be affected and how soon, which jobs can be enhanced with AI, and most importantly, how we can provide solutions to some of the most profound changes in human history that are coming soon.
'Eh? See Sinovation Ventures.


Cool logo.

ERRATUM

Screen cap from my iPhone:

Ugh.
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More to come...

Tuesday, September 18, 2018

Hashtag #health2con

Hate to have to miss the Conference this year, but you can easily follow near- real time twitter updates here:



THE Health IT event of the year.
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More to come...

Thursday, September 13, 2018

"Exposomics"?

"This volume presents a comprehensive overview of the science and application of the Exposome through seventeen chapters from leaders in the field. At just over ten years since the term was coined by Christopher Wild in 2005, this is the first, field-defining volume to offer a holistic picture of the important and growing field of Exposomics. 

The term “Exposome” describes the sum of all exposures (not only chemical) that an individual can receive over a lifetime from both exogenous sources (environmental contaminants, food, lifestyle, drugs, air, etc.) and endogenous sources (metabolism, oxidative stress, lipid peroxidation, chemicals synthesized by the microbiome, etc.). The first section of this book contains chapters that discuss how the Exposome is defined and how the concept fits into the fields of public health and epidemiology. The second section provides an overview of techniques and methods to measure the human Exposome. The third section contains methods and applications for measuring the Exposome through external exposures. Section four provides an overview on statistical and computational techniques- including big data analysis - for characterizing the Exposome. Section five presents a global collection of case studies."
 A.K.A. (or closely related to) "epigenomics?" How about "HGT?" (Horizontal Gene Transfer). Where does that fit? Related to "the Upstream?" 

And, again how will all of this fit into the exam room / bedside patient encounter in the "productivity treadmill" front-line world?

 Got onto this topic via STATnews:

From the moment of conception onward, genes control our development and health. But they don’t do it alone. The exposome — all the internal and external chemical exposures we experience during the course our lives — influences, for better or worse, the genes and proteins they code for. A better understanding of the exposome, a concept still in its infancy, will help identify how nongenetic factors influence biological reactions and possibly the development of chronic diseases...
apropos,


AGAIN: SEPT 16TH - 18TH, 2018

THE Health IT event of the year.
Be there. I will hate to miss this. Applied for my usual press pass. Never heard back, but, it's likely moot, given my post-op convalescence (which is proceeding apace, thought the daily conference schlep might be a bit much for me at this point).
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More to come...

Tuesday, September 11, 2018

My cardiac surgeon



I had my first follow-up office visit today in the wake of my SAVR px. All signs looking good. I asked Dr. Veeragandham whether he would mind my citing him here on the blog. I didn't want to presume. He gave me the green light.

I owe my life to this man and his team at John Muir Cardiovasular Institute (inclusive of the support teams staffing the ICI and PCU).

As I was in pre-op on the 23rd, someone remarked, "oh, you got the A Team."

No exaggeration. Not one whit. Back in June when I had my hernia px, my anesthesiologist said of Dr. V., without hesitation, "if I needed to have something done, he'd be my guy."

I asked Dr. V. about "pumphead." He replied convincingly to not worry about it. I joked "how would I even know? I stay confused as it is."

He also told me I'd be OK to drive again in another week (I'm in no hurry).

You gonna need cardiac surgery? You simply can't do any better, IMO. Both in terms of technical skills and effusive beneficent humanity.
I just filled out my Press-Gainey. Gave 'em all high marks.
Some prior posts alluding to my SAVR anticipation and experience here.

SHORTLY: SEPT 16TH - 18TH, 2018
THE Health IT event of the year.
Worth every penny.

apropos of the Conference and "innovation," a book I just finished.


Nicely done. More ASAP
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More to come...

Sunday, September 9, 2018

SAVR px progress


Prior to surgery I could max out the spirometer repeatedly with ease. Then, post-op, in the ICU and PCU (Progressive Care Unit), I could barely move it.

I'm now back to pinning it at 2,500 ml multiple times in a row here at home. Doin' OK. Vitals are stable (resting pulse is rather high, though), I'm out walking about 1/3rd mile at a time. Way less pain than I'd expected. Lost about 16 lbs. Fine with that. Two f/ups this week, my surgeon and cardiologist. Should be interesting.

One of my new reads:


Science Magazine book reviews are gonna bankrupt me, LOL...

AGAIN, SAVE THE DATES: SEPT 16TH - 18TH, 2018
THE Health IT event of the year.
Be there.

ERRATUM

Binge-watching.


Can't say enough good about this production.
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More to come...

Tuesday, September 4, 2018

Coming soon, the 2018 Health 2.0 Annual Conference

Indu and Matthew, 2017 Conference
In my email inbox today.
Hello there!

With our flagship Fall Conference just three weeks away, we’re getting very excited to see you there! Health 2.0 is where accountability reigns and truth gets a platform. Our community of health care rabble rousers continues to raise the bar and create a global movement of innovation. With our signature candor, we promise to highlight the big ideas and untangle the tough questions. This year we’ll be asking each other and all of you…
 
1. Matthew: Is this the year the bubble bursts? 
Indu: Maybe it’s not a bubble.  Maybe this is exactly the level of investment we need to get to the change and real value creation we need.  I’m bullish.

Matthew : Maybe to change a $3.5 trillion industry, it’s not enough….yet. Could use a few more IPOs though….
2. Indu: Is blockchain BS?
Matthew: Well my bitcoin is down 50% since I boasted to you how rich I was in January! But Deloitte says 75% of health care execs say their understanding of blockchain is “excellent,” 39% say it’s in their top 5 priorities but only 11% say they are deploying blockchain somewhere in their enterprise. I actually think that’s quite high!
3. Indu: Is everyone just giving value-based care lip-service? A survey by the American Medical Group Association in 2015 showed that payments from commercial payers were still heavily Fee for Service, 78%. And another 2016 survey showed that only 43% of physicians’ compensation is tied to quality or value!
Matthew: Well I did a survey on this very topic in 1997 at the height of the managed care revolution--only about 10% was NOT fee for service then. So we have seen some change.
Indu: Not enough.
4. Indu: Will Blue Button 2.0 move the needle forward?  
Matthew: Still not sure what was wrong with Blue Button 1.0! But nearly 1,000 developers are using the CMS sandbox and insurers are participating in the CARIN Alliance. As Stephen Stills sang, "there’s something happening here…”
5. Indu: Is Seema Verma correct that the end of the fax machine is near?
Matthew: Not per my last experience with my kid’s pediatrician...but I’m hopeful. She did say 2020.
6. Matthew: Is Amazon’s health care takeover our golden ticket?  
Indu: Depends on what you mean by “our?”  I don’t think Amazon is going to kill the digital health tech market, if anything I think it enriches the market with new supply chains and a new standard for customer experience and competition. I do think it stands to hurt health systems.  But health systems have had lots of lead time to respond and consolidation in that sector hasn’t helped cost structures or outcomes.  So what else could they be doing? Come to the conference and find out ;)

Matthew: I agree with all that, but you did say “digital health”. Grrr.
7. Matthew: Will free medical school actually alleviate the global physician shortage and encourage the right kind of physician experience?
Indu: No, but it’s a start. We have to humanize the experience of training and practicing so clinicians don’t burn out.
Matthew: Like you did?
Indu: If I hadn’t left medicine, we wouldn’t be working together!
Matthew : So I’m responsible for humanizing you? Or hasn't that happened yet?
8. Matthew: Is the Opioid epidemic a data problem or a social one?
Indu: Yes. But seriously, we have an incredible segment on this on the Unacceptables. Basically complex problems require ecosystem solutions and technology can be the connective tissue here.
 9. Matthew: How are the dinosaurs of old school care delivery adapting to tech disruptors?
Indu: They’re turning into birds!
10. Indu: Is digital health dead?
Matthew: The term digital health is the zombie I can’t quite kill!
We’re not new, and it takes a lot to impress us. Now in our 12th season, with a close eye on trends and a heavy hand in curation we’ve set the stage for another class of investments, partnerships, and launches to bring you into 2019 and beyond.
 
Join us this September 16-18 in Santa Clara. As a friend of ours, feel free to use the code VIP for $200 off! We can’t wait to see you there.

Indu Subaiya & Matthew Holt

DON'T FORGET TO SAVE THE DATES: SEPT 16TH - 18TH, 2018

THE Health IT event of the year.
I will miss you all this year. My post-op recovery is going along pretty well, but I doubt I'll be up to attending.
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More to come...

Wednesday, August 29, 2018

SAVR px post-op discharge week

I'm home. Discharged at 2 pm yesterday. Thanks to everyone for your kind words of concern and support.


Well, that was indeed interesting. Lots to think about and recount as I gather my thoughts. Stay tuned.

For now, Major Props to my surgical team and all of the Muir Concord Cardiovascular center staff.
__

OH, YEAH, 
DON'T FORGET TO SAVE THE DATES: SEPT 16TH - 18TH, 2018

THE Health IT event of the year.
I don't guess I'll be attending this year (I've covered the past six). I applied for the press pass, but never got a response, but, as a practical matter I doubt I'd be physically up to it. Hate to miss it.

ERRATUM

RIP Senator John McCain.




Whatever you thought of his politics (and I was mostly not a fan), he served courageously, and suffered mightily for our country.

WEEKEND UPDATE


My offending aortic valve. Quite frankly, I'm lucky to be alive. There was probably heart valve failure or a stroke in my not-to-distant future.

I'm having a lot to continue to adjust to at home this week (a lot of it related to fastidious antiseptic hygiene measures). I'm out walking every day. Reading a lot. Tire easily. Vitals are stable.

My medical economist and writer pal JD Kleinke has warned me about the risk of "pump brain." Yeah, bro', I saw that in my Dad after his heart surgery in 1996.

Among my frustrations is that I will not be able to play my guitar for another 6-8 weeks (sternum pressure). Grrrr...
On a terribly sad note, I got a call from my close Seattle friend "Joey T's" cell yesterday. It was his wife Kathy, calling to say he'd died the other day from brain mets stemming from his bladder cancer. He'd been doing better of late, but things took a rapid turn south. Joey and I had talked at length about his cancer repeatedly. I knew he'd been struggling. Nonetheless he showed up unannounced at Danielle's Memorial. That is a friend.
Very sad.
__

UPDATE
SAVR the experience. 


Up at 3:45 a.m., after a difficult, anxious, short night's sleep. No foods of liquids allowed. Ugh. Off to Concord, arriving at the Cardiovascular Institute at 5:23. Preregistered, straight up to “Short Stay” on the 2nd floor to begin pre-op prep. First (after vitals and a bunch of Consent signatures), neck-to-ankles full-frontal body shave (“OMG! I’m a Foster Farms Thighs & Breasts Valu-Pack!), then blood draws and chest x-rays. IV insertions next (both arms), and EKG telemetry hookups follow forthwith.

Quick discussions ensue informing my wife and sister as to where to go to wait and what to expect in the way of surgery progress notifications. The anesthesiologist comes by to introduce herself and chat reassuringly. My cardiac surgeon stops by to warmly greet and further encourage me. Cardiac staffers would subsequently remark, on multiple occasions, “boy, did you ever get the A-Team!”

All good to hear. My anxiety is pretty minimal, all things considered, but it would not be true to claim there wasn’t any. I guess I’ll wake up. Or not.

More prep — lost of stuff going on all around me in tandem — and then it’s off to the OR.

They sidle my gurney up aside the operating table, which has a large stainless steel hump on it. I’m instructed to slide over on to it, with my upper-mid back positioned over the hump. It’s uncomfortable…

That’s the last thing I remember until waking up several hours later in Cardiac ICU (it seemed like mere minutes). Eventually the intubation is removed, I and have episodic bouts of harsh coughing. Right away they push me to begin using the spirometer. Pre-op I’d been pinning it at 2,500, no sweat. Now I can barely get it to move.

In short order I start intractable bouts of rather harsh, persistent hiccups from my irritated windpipe, some of which last 2-3 hours at a time through Saturday. Nothing works to abate it. They finally resort to two sequential IM doses of thorazine, which knock me out.

I will never EVER do thorazine again. You can just forget it. The most vivid adverse side effect was my mouth feeling like the surface of planet Mercury. Bone dry. By Saturday evening I was totally exhausted.

But, that aside, rehab progress began right away. Sitting up, doing minor PT extremities’ exercises, then standing, then a walk down the hall using a walker.

By Saturday I’m moved from ICU down to the PCU (Progressive Care Unit). I quickly regain my “sea legs” and start stably lapping the PCU floor around the nurses’ stations, doing 4-6 laps at a time rather than the expected one or so.

Struggle to eat. Hospital food, man, particularly for us cardiac pts. Like eating cardboard. Ugh. I struggle to down some chow that I know I need.

By Monday, the tentative talk is that I might be able to go home Tuesday (thought my surgeon equivocates a bit). Those damned hiccups have cost me at least one additional post-op inpt day.

On Tuesday, though, the consensus on Rounds (my surgeon, my cardiologist, and his on-call practice colleague) is that yeah, I’m good to go.

More reams of paperwork, and then a protracted hurry-up-and-wait interval.

Finally, at 1:50 pm, an aide with the requisite wheelchair comes for me. Loaded into the car curbside, I have to sit in a back seat (airbag risk).

Homeward bound. Pretty happy camper at this point.

I can’t say enough good about my entire care team.

Some thoughts about my workflow observations shortly (yeah, I can't help it, I'm always watching and counting). Stay tuned.
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More to come...

Monday, August 20, 2018

SAVR px week


Thursday morning I'm getting my severely stenotic aortic valve replaced (via the "old-fashioned" open-heart SAVR px, same one my late Dad had 22 years ago at age 80). I am out of time. I've pushed the envelope all the way, owing mostly to Danielle's illness. See "My 'Check Engine' light." So, I'll probably be off line for a bit. Friday is likely to be a crappy day in the cardiac ICU. I'm told to expect 4-8 days in the hospital, depending on my post-op progress.

Interesting: During my pre-op visit last Thursday, among the many tests they ran on me was a nasal swab for "Staph au."

Then I ran across this in a book I just started:
...the global medical challenge of antibiotic-resistant bacteria, a quiet crisis destined to become noisier. Dangerous bugs such as MRSA (methicillin-resistant Staphylococcus aureus, which kills more than eleven thousand people annually in the United States and many more thousands around the world) can abruptly acquire whole kits of drug-resistance genes, from entirely different kinds of bacteria, by horizontal gene transfer. That’s why the problem of multiple-drug-resistant superbugs—unkillable bacteria—has spread around the world so quickly. By such revelations, both practical and profound, we’re suddenly challenged to adjust our basic understandings of who we humans are, what has gone into the making of us, and how the living world works.

Quammen, David. The Tangled Tree: A Radical New History of Life (Kindle Locations 65-71). Simon & Schuster. Kindle Edition.

My assays were negative. The pre-op nurse had told me that the general environmental staph contamination prevalence was now at about 30% (meaning, were you to touch anything randomly while out in public, you'd have ~30% chance of coming in contact with the staph bug).

More on David Quammen's book here, from Science Friday. Looks like a great read. "HGT?" (Horizontal Gene Transfer). Great. Add one more complex phenomenon to the "Omics" pile for medical science and practice to have to weed through.

UPDATE

 

Yeah. I've talked to a bunch of my friends who've been through Open Heart px's. Comforting.

OK, THIS IS FUNNY

From Science Based Medicine:
Bouffant caps versus skull caps in the operating room: A no holds barred cage match
Over the last few years, AORN and the American College of Surgeons have been battling it out over AORN’s 2014 guideline that has increasingly led to the banning of the surgical skull cap in the operating room in favor of the bouffant cap. Lacking from this kerfuffle has been much in the way of evidence to support AORN’s guideline, but unfortunately that didn’t stop the ACS from appealing mainly to tradition and emotion in objecting to it...
I guess I'll be looking.

8-22 ERRATUM


SAVE THE DATES: SEPT 16TH - 18TH, 2018

THE Health IT event of the year.
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More to come...

Thursday, August 16, 2018

Pancreatic cancer claims another one

Rest in peace, Aretha Franklin


Died at home, in hospice care. We know it all too well. She and our Danielle shared similar risk factors.

Only 76. Very, very sad. Our hearts go out to her family. This old washed-up guitar player knew her music so well.
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More to come...

Monday, August 6, 2018

EBM and the SOAP process

Interesting inexpensive resource ("EBM," Evidence-Based Medicine -- as opposed to "Eminence-Based Medicine"):

Foreword
This short book provides the skills and tools to empower the reader to make better sense of clinical evidence. Present-day journal articles reflect ever-increasing complexity in research design, methods and analyses, and this welcome addition to the field will help readers to get the most from such papers.

With a little practice the book will indeed make it easier to understand the evidence related to healthcare interventions; it provides a clear and accessible account across the whole subject area. The authors avoid unnecessary jargon and have designed the book to be flexible in its use – it can be read from cover to cover or dipped into for specific topics.

Clinical Evidence Made Easy is helpfully structured into two main sections. The first provides the reader with the necessary skills underpinning evidence-based practice, the second gives invaluable tools for appraising different types of articles together with practical examples of their use. Moreover, the configuration within the sections makes for easy reading: common headings are used across chapters so that the reader quickly becomes familiar with the structure and the way ideas are presented.

This is a great book for busy clinicians who want to learn how to deliver evidence-based practice and have at their fingertips the tools to make sense of the burgeoning research literature. Indeed, it will also be valuable for those engaged in research, to aid the planning and delivery of their own projects.

Preface
This book is designed for healthcare professionals who need to know how to understand and appraise the clinical evidence that they come across every day.

We do not assume that you have any prior knowledge of research methodology, statistical analysis or how papers are written. However basic your knowledge, you will find that everything is clearly explained.

We have designed a clinical evidence appraisal tool for each of the main types of research method. These can be found in the second section of the book, ‘Clinical evidence at work’, and you can use them to help you evaluate research papers and other clinical literature, so that you can decide whether they should change your practice…


Harris, Michael; Harris, Michael; Taylor, Gordon; Taylor, Gordon; Jackson, Daniel; Jackson, Daniel. Clinical Evidence Made Easy. Scion Publishing. Kindle Edition. 
I am liking it. Fairly comprehensive topical coverage.
TABLE OF CONTENTS

Understanding clinical evidence
1. The importance of clinical evidence
2. Asking the right questions
3. Looking for evidence
4. Choosing and reading a paper
5. Recognizing bias
6. Statistics that describe
7. Statistics that predict
8. Randomized controlled trials
9. Cohort studies

10. Case–control studies
11. Research on diagnostic tests
12. Qualitative research
13. Research that summarizes other research
14. Clinical guidelines
15. Health economic evidence
16. Evidence from pharmaceutical companies
17. Applying the evidence in real life

Clinical evidence at work

18. Asking the right questions
19. Choosing the right statistical test
20. Randomized controlled trials
21. Cohort studies
22. Case–control studies
23. Research on diagnostic tests
24. Qualitative research
25. Research that summarizes other research
26. Clinical guidelines
27. Health economic evidence
28. Evidence from pharmaceutical companies
29. Putting it all together…
WHAT COUNTS AS "EVIDENCE?"

* They fail to fully make clear whether "external clinical evidence" refers only to that of clinical literature, and does not include patient exam and testing data. I have to assume that eval of exam room/bedside data comes under "clinical expertise."

More broadly. "evidence" is information (typically comprising lexical/discoursive and more structured alphanumeric "data") that makes a true conclusion more likely (or, more rarely, constitutes dispositive "proof").
A "fallacy" is any assertion purporting to contain "evidence" but in fact does not. Fallacies are legion, both structural/formal, and "informal/rhetorical." Also worth noting here are the numerous "cognitive biases" that chronically afflict our ability to "reason" accurately. I have long been a student of this stuff, and spent a number of fun years teaching post-secondary "Critical Thinking."

THE SOAP PROCESS

Subjective - Objective - Assessment - Plan

Simple example here.
NOTE: My former Sup in the Meaningful Use program, Keith Parker, argued that "SOAP" should properly be "SOAPe" ("e" for Evaluation). Scroll down in this post. He's right.

A cute, brief YouTube SOAP note video:

 

"CHEIF COMPLAINT"? Lordy. Nonetheless...

A couple more of my graphic riffs on the process.


"SOAP Note" on the wiki.

I've noted the point many times that there's a lot going on in the exam room, usually with insufficient time for deeply deliberative assessment given the still-dominant economic regime of the "Productivity Treadmill."

BACK TO CLINICAL EVIDENCE MADE EASY

Search the text for "SOAP." Nothing. Search the text for "Bayes" and "Bayesian." Nothing.
(Nothing either for "exam," "differential," "rule out," "digital," "EMR," "EHR," "electronic.")
"P Value?"

23 hits. to wit,
The P value

The P value gives the probability of an observed difference having happened by chance.

P = 0.5 means that the probability of a difference having happened by chance is 0.5 in 1, or 50%.

P = 0.05 means that the probability of the difference having happened by chance is 0.05 in 1, or 5%. This is the level when we traditionally consider the difference to be sufficient to reject the null hypothesis.

The lower the P value, the lower the likelihood that the difference occurred by chance and therefore the stronger the evidence for rejecting the null hypothesis and concluding that the intervention really does have a different effect. As the P value that is normally used for this is 0.05, when P < 0.05 we can conclude that the null hypothesis is false…
[op cit, pg 38]
Yeah. That's the way they continue to teach it. Way simplistic. First a "p value" is a probability estimate, one that will also yield a variability distribution in the wake of repeated trials. Second, it assumes a perfectly Gaussian distribution (bell curve). See a 1996 ASQ newsletter column of mine, "Probability from 'C' to 'G'." (pdf)


I worked in credit risk modeling and management for five years (large pdf link). We never took p-values and distributional assumptions at face value. The name of the game was (and is) stress-tested expected value computations. We made successive record profits every year I was there. (Wrote about that time in my life here.)
In fairness, the authors do make one brief cite concerning a statistical test useful for "skewed data." But, just one simple example.
INITIAL SUMMARY TAKE

I've not read the book closely yet, but I have skimmed the chapters, and I do like what I find therein. Every chapter closes with a "Putting it all together" closing paragraph or two. It's really about assessing the "external clinical evidence" originating beyond the exam room or patient bedside.

I am a regular at SBM, the "Science Based Medicine" blog. You might like the search results there for "Evidence-Based Medicine."
There is a bit of pedantic nit-picking out there as to whether EBM differs materially from SBM. I don't think so. From the SBM site:
"Good science is the best and only way to determine which treatments and products are truly safe and effective. That idea is already formalized in a movement known as evidence-based medicine (EBM). EBM is a vital and positive influence on the practice of medicine, but it has limitations and problems in practice: it often overemphasizes the value of evidence from clinical trials alone, with some unintended consequences, such as taxpayer dollars spent on “more research” of questionable value. The idea of SBM is not to compete with EBM, but a call to enhance it with a broader view: to answer the question “what works?” we must give more importance to our cumulative scientific knowledge from all relevant disciplines."
Interesting.

Again, "Evidence" -- "that which makes a true conclusion more likely." It behooves us keep in mind that evidence itself spans a distribution, e.g.: "nil - weak - indeterminate - likely - dispositive." Gets even hairier when you add in "conjuncts" i.e., "given this and that, and that over there..." (just for starters).

I think about this stuff all the time. But what spurred this post in particular was this cool Atlantic article:


Yeah. Which returns me to this book I've been studying. Cited it earlier.


Below, another one I need to report on. Goes to the EBM thing.


Beyond those, a number of additional recent books inform my thinking (many of which I've cited on the blog before):
The Enigma of Reason
The Knowledge Illusion
The Distracted Mind
The Secret Life of the Mind
Touching a Nerve
World Without Mind
How to Think
Big Mind
Truth
The Book of Why
Snowball in a Blizzard
How Doctors Think
Thinking, Fast and Slow
Moral Tribes
More Harm Than Good
Changing minds
Levers of Influence
Pre-suasion
How to Change Your Mind
Being Wrong
There are more, but this will do for now on the topics relating to cognition. My long-time abiding interest goes to improving diagnostic (and px/tx) reasoning via understanding and explicating the salient aspects of rational clinical cognition. Inextricably intertwined with this is an understanding of the relevant aspects of Health IT. To the extent that the latter impedes the former (poor UX), well (as many complain), it contributes to adversity.

ERRATUM

18 days 'til my heart surgery. Keep singing "woke up this mornin'..." 18 more times.

AUG 7TH UPDATE ADDENDUM

apropos of continuing to wake up, saw a post about this book over at THCB.


Amazon link here. Looks interesting. I am reminded of Ann Neumann's book The Good Death.



COMING SOON


Interesting. Stay Tuned. Source, a WIRED article.
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More to come...