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Monday, November 19, 2012

RECs: don't get run over; you won't make the local news.

Every time I look around, I run across incredible promising new initiatives.
Is stuff like this all sizzle, no steak?

Speaking of steak...
Mindful eating helps lower weight and reduce blood sugar
Nicole Concepcion, November 17, 2012

Eating mindfully is just as effective as adhering to nutrition-based guidelines in reducing weight and blood sugar levels in adults with Type 2 diabetes, a new study at Ohio State University suggests...
Yeah. My hardcore friends at might proffer a lot of pushback on this idea. But, eating is more than just consuming nutrition and fuel. To an excessive degree in my culture it's additional "entertainment" and "narcotization."

Lots to think about here. But. first, I'm off to my daughter's house to engage in some convivial, unmindful BBQ.


Good post up today, "True informed consent is elusive." As is customary, the comments are frequently as good as the posts. A snip, to wit:
The problem is that most medical students don’t understand or like statistics. EBM and ethics are the two areas of med school that are traditionally trudged through just to barely pass so we can do the “other stuff.” I cannot tell you how many med students, residents, and even fellows I have met who just throw up their hands and say with exasperation that they just don’t “get” math and just to give them the conclusion of a study so they can practice however it says. I’ve even had a heme-onc attending once comment that a Bayesian framework is “hard” and she never bothers with that and a resident with a PhD misunderstand the implication of a Bayesian prior changing the p-value and thus the significance of a study...
I have found this to be the case across the breadth of fields within which I've worked (including credit risk management). Moreover, I served as an undergrad researcher for a doctoral dissertation on the topic of math anxiety and the teaching of college-level statistics. I was blessed to have come to my stats education at UTK via the Philosophy Department ("Deductive Logic," "Inductive Logics," and "Philosophy of Science"), so the Business School and Math Department didn't get a chance to mess with my mind once I got deeper in the curricular weeds.

This commenter hits the nail right on the head.


"Hi, Doc! I used my on-line
portal to make an appointment!"

The Electronic Health Record (EHR) On-Line Portal Increases Hospitalization Rates

Hey there Accountable Care Organization executive.

You're probably willing to continue to commit millions of dollars toward an electronic health record (EHR) coupled to an online patient portal.  That's because you've been told by your leadership team that electronic consumer empowerment, patient-provider communication and the substitution of efficient two-way messaging for costly face-to-face visits will increase quality, reduce expenses, generate shared savings and guarantee that your life-sized portrait will be prominently displayed in your flagship hospital's lobby.

Well, after you've read a just-published JAMA research study by Ted Palen, Colleen Ross, David Powers and Stanley Xu, you may want to tell your administrative assistant to cancel that appointment with the portrait artist...

The article's title is Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services.

The results:
Compared to non-MHM patients, the MHM experienced an increase in hospitalization rates (20 per thousand patients) and emergency room visits (11 per thousand).  In other words, for every hundred patients, the on-line portal seemed to lead to 2 extra hospitalizations and 1 extra ER visit. Both differences were statistically significant...

Despite the limitations, this study should be a wake-up call for those who believe EHR portals is a savings panacea.  By increasing access to on-line services, physicians and patients may paradoxically use the system to address concerns that otherwise wouldn't come to medical attention.  In other words, the EHR portal exacerbates the classic health care economics problem of supplier-induced demand.
You would do well to read the entire study report. There's way less here than meets this author's eye.


Recall my November 11th post "Big Data..." wherein I alluded to the book I bought entitled  "Genetic Justice"? Well, I am eyeball deep down in the weeds reading up on the authors' take on genetic labs' "accuracy and precision" (they are not one in the same).

I am not particularly comforted at this point, though I feel like months of research await me, nothwithstanding my legacy chops in lab QC. DNA assay is at once very different and remarkable similar to other biochemistry bench methods.

OK, so, tangentially, check out this methodological slasher film.

Hacking the President’s DNA
The U.S. government is surreptitiously collecting the DNA of world leaders, and is reportedly protecting that of Barack Obama. Decoded, these genetic blueprints could provide compromising information. In the not-too-distant future, they may provide something more as well—the basis for the creation of personalized bioweapons that could take down a president and leave no trace.

...While no use of an advanced, genetically targeted bio-weapon has been reported, the authors of this piece—including an expert in genetics and microbiology (Andrew Hessel) and one in global security and law enforcement (Marc Goodman)—are convinced we are drawing close to this possibility. Most of the enabling technologies are in place, already serving the needs of academic R&D groups and commercial biotech organizations. And these technologies are becoming exponentially more powerful, particularly those that allow for the easy manipulation of DNA.

The evolution of cancer treatment provides one window into what’s happening. Most cancer drugs kill cells. Today’s chemotherapies are offshoots of chemical-warfare agents: we’ve turned weapons into cancer medicines, albeit crude ones—and as with carpet bombing, collateral damage is a given. But now, thanks to advances in genetics, we know that each cancer is unique, and research is shifting to the development of personalized medicines—designer therapies that can exterminate specific cancerous cells in a specific way, in a specific person; therapies focused like lasers.

To be sure, around the turn of the millennium, significant fanfare surrounded personalized medicine, especially in the field of genetics. A lot of that is now gone. The prevailing wisdom is that the tech has not lived up to the talk, but this isn’t surprising. Gartner, an information-technology research-and-advisory firm, has coined the term hype cycle to describe exactly this sort of phenomenon: a new technology is introduced with enthusiasm, only to be followed by an emotional low when it fails to immediately deliver on its promise. But Gartner also discovered that the cycle doesn’t typically end in what the firm calls “the trough of disillusionment.” Rising from those ashes is a “slope of enlightenment”—meaning that when viewed from a longer-term historical perspective, the majority of these much-hyped groundbreaking developments do, eventually, break plenty of new ground.

As George Church, a geneticist at Harvard, explains, this is what is now happening in personalized medicine. “The fields of gene therapies, viral delivery, and other personalized therapies are progressing rapidly,” Church says, “with several clinical trials succeeding into Phase 2 and 3,” when the therapies are tried on progressively larger numbers of test subjects. “Many of these treatments target cells that differ in only one—rare—genetic variation relative to surrounding cells or individuals.” The Finnish start-up Oncos Therapeutics has already treated close to 300 cancer patients using a scaled-down form of this kind of targeted technology.

These developments are, for the most part, positive—promising better treatment, new cures, and, eventually, longer life. But it wouldn’t take much to subvert such therapies and come full circle, turning personalized medicines into personalized bioweapons. “Right now,” says Jimmy Lin, a genomics researcher at Washington University in St. Louis and the founder of Rare Genomics, a nonprofit organization that designs treatments for rare childhood diseases based on individual genetic analysis, “we have drugs that target specific cancer mutations. Examples include Gleevec, Zelboraf, and Xalkori. Vertex,” a pharmaceutical company based in Massachusetts, “has famously made a drug for cystic-fibrosis patients with a particular mutation. The genetic targeting of individuals is a little farther out. But a state-sponsored program of the Stuxnet variety might be able to accomplish this in a few years. Of course, this work isn’t very well known, so if you tell most people about this, they say that the time frame sounds like science fiction. But when you’re familiar with the research, it’s really feasible that a well-funded group could pull this off.” We would do well to begin planning for that possibility sooner rather than later...
Figures. The ethical flip side of personalized medicine. We humans are a mortally dangerous species, too clever by orders of magnitude relative to our aggregate evolved moral anchoring.

This is The Atlantic Monthly, not some hyperbolic tabloid rag. Read all of this piece.


Is there room for two not-for-profit HIEs in Nevada?

Long answer? No.

Interesting politics on all of this.

The 2012 Deloitte-AMIA Health Informatics Industry Maturity Survey. Insights on the State of Informatics in Health Care

Meaningful use. Accountable care. Comparative effectiveness. These are all concepts that were not part of the common vernacular of health care as recently as five years ago but are now primary drivers of transformational change in the health care industry. These concepts — the meaningful use of electronic health records (EHRs) as part of the Medicare and Medicaid incentive program under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009; the creation of accountable care organizations (ACOs) under the Patient Protection and Affordable Care Act (ACA) of 2010; and the increasing interest in understanding the relative value of various medical treatment options through the conduct of comparative effective research (CER) — all share a common enabler: health informatics (HI).

Without health informatics, the use of EHRs has little meaning beyond data capture and retention; care cannot be readily coordinated or outcomes tracked to support accountable care; and sufficient data to make correct comparisons between therapeutic modalities cannot be gathered and analyzed...


Well, still no HIPAA Omnibus Final Rule in the Federal Register. But, at health we have stuff like this:

More to come...

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