California State HIT Day

Got here without a problem (getting up at 5 was the problem). 82 miles, took only about 80 minutes, right up the 680 to the 80 to the 5 to L Street, NPR all the way on the radio. 15th floor of the Hyatt, overlooking the state Capitol.

Beautiful day. Packed agenda, much to see, hear, learn, and document.

THOMAS S. KEEFE, MA, Keynote Speaker

Senior Director, State Government Affairs.

"HIMSS State Health IT Days are some of the most important HIMSS events each year. Supported by HIMSS Chapters and HIMSS State Government Affairs, State Health IT Days aim to connect subject matter experts in health IT with their state elected officials to foster relationship building and education. Typically conducted when a state legislature is in session, a State Health IT Day may include meetings with legislators, site visits to healthcare facilities and presentations from policy experts. Alternatively, a chapter may use virtual technologies to plan a State Health IT Day or one focused on visiting state legislators within their home districts to ensure mass participation across their state..."

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POST KEYNOTE GROUP PHOTO-OP

I got drafted into photographer duty. My first "official act" as a HIMSS NoCal member.

Above, Salim Kizaraly of Stella Technology.

Nancy Hall, HIMSS NoCal Board Member and CIO panel moderator

Dave Minch, President & COO Health Share Bay Area

Above: CALHIPSO's Speranza Avram reported on the status of the ONC's REC program, from which I recently retired. She nailed it pretty well.

Above: Pamela Lane, MS, RHIA, CPHIMS, Deputy Secretary for Health Information Exchange Director for the Office of Health Information Integrity California Health & Human Services

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LEGISLATIVE "ADVOCACY"

I'd not really understood this, but a couple of afternoon hours were slated for going across the street to the state Capitol to buttonhole legislators or their staffs to "advocate" (not "lobby") for Health IT support.

Interestingly, there was a loud concomitant health care reform rally ensuing on the Capitol grounds.

Nice. I first made my way to the adjacent park's statue of Friar Farzad, Patron Saint of Interoperability on my way to "my representatives'" offices.

Just kidding, obviously.

On to tout "the Ask."

Notwithstanding that I am still a legal resident of Nevada, I've been paying California state income tax for nearly 5 years as a result of my wife's work in Walnut Creek (Cheryl has had to become a California legal resident), so these legislators are in my view my reps as well in a very real, quantifiable sense.

I candidly made that clear while talking with their staffs, and they were fine with that. Nice people, all of them. They were graciously generous with their time, in part no doubt because I'm now "Health IT Press," and nothing gets pols' attention like the words "constituent" and "press" in the same sentence.

All in all, a fun day. Met a lot of fine people. Learned some stuff. Can't ask for more than that.
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More to come...

Upstream, downstream; what happens to health when there IS no more stream?

I've had a pretty good recurrent go at the so-called "upstream" issues pertaining to health, e.g., here, and here, for example. The assertion is made that perhaps 90% of human health is atributable to "upstream" factors outside the clinical care delivery system: genetics (to the extent that they are still considered "outside of care delivery"), lifestyle factors, culture, poverty, pollution, and environmental factors more broadly.

California, where I now live, is in the clutches of a severe and prolonged drought, one possibly lurching toward the catastrophic (statewide, we have less than a year's supply left, by some estimates).

The image above is from a current New Yorker article "The Dying Sea."

The Dying Sea
What will California sacrifice to survive the drought?
by Dana Goodyear

...In early April, the governor of California ordered the state to conserve a million and a half acre-feet of water in the next nine months, a drastic response to an intensifying four-year drought that has devastated small communities in the north, decimated groundwater supplies in the Central Valley, and made the cities fear for the future. To achieve this savings, Californians are starting to forgo some of the givens of life in modern America: long showers, frequent laundering, toilet-flushing, gardening, golf. It can be hard to visualize a quantity of water. An acre-foot is what it takes to cover an acre to the depth of twelve inches: some three hundred and twenty-five thousand gallons. A million acre-feet is about what the city of Los Angeles uses in two years. A million acre-feet, give or take, is also how much runs off to the Salton Sea each year from the farms of the surrounding Imperial Valley. Salty, spent, and full of selenium and phosphates, the excess water flows down to the sea, where, two hundred and thirty feet below sea level, it evaporates under a blistering sun...

Indeed. In our household, we have reduced the frequency and length of our showering, reduced toilet flushing, -- "if it's yellow, let it mellow" -- and routinely capture the water that runs from the taps while awaiting needed hot water. The yard is slowly turning brown, as are the surrounding hills of Contra Costa County. The terms of our lease state that "drought conditions are not considered 'acts of God' for purposes of this agreement, and the lessee shall be responsible for maintaining the vegetation on the property in healthy condition through application of sufficient irrigation watering." While that provision is probably unenforceable in the wake of Governor Brown's recent statewide drought Executive Order, it would not surprise me were my landlord to dun us for "landscape damage" by withholding some of our $3,000 deposit were we to move.

There are projections that residential water rates may soon triple. Critics of that approach bemoan the anti-regulatory "libertarian" socioeconomic "efficient markets" tactic of "rationing by price," given that the most affluent residents may simply shrug their shoulders and pay. After all, there are tee times to be had, Lexuses to be washed, and pools to remain filled.

We've been considering buying a house, one closer to my wife's office, but -- current market prices and earthquake considerations aside -- predictions are emerging forecasting a severe housing market downturn by 2017 or so should the drought persist and worsen. At our ages, we don't have time to make a bad housing move and slide -- well,  "underwater." We're fortunately now among the very small minority of incipient retirees with money in the bank (including healthy IRAs), positive net worth, no debt, and positive cash flow. A mortgage gone south might well negate all of that.

Portugal is starting to look pretty good. ;)

LOL. Everyone should have my problems.

Back to "The Dying Sea." and "upstream health issues."

Between the needs of the city and the farmers sits the Salton Sea, which conservation will destroy. “The sea is the linchpin between Colorado River water and urban Southern California,” Michael Cohen, a senior research associate at the Pacific Institute, a water-policy think tank, says. Without the inflows, the sea, already shrinking, will recede dramatically, exposing miles of lake bed loaded with a hundred years’ worth of contaminants. Much of the wildlife will disappear—poisoned, starved, or driven off. The consequences for people around the region could be dire, too. Before irrigation, the valley was plagued by violent dust storms. With the water gone, the lake bed could emit as much as a hundred tons of fine, caustic dust a day, leading to respiratory illness in the healthy and representing an acute hazard for people with compromised immune systems. No one knows how far that dust can travel on the wind. Mary Nichols, the state’s top air-quality official, says, “The nightmare scenario is the pictures we’ve all seen of the Dust Bowl that contributed to the formation of California in the first place.”

Last year, when Axel Rodriguez was four, he started coughing, a weird cough that sounded like a drum, deep and percussive, and scratchy, as though something inside his chest were trying to claw its way out. The cough would go away for a few days, only to come back stronger.

Axel’s mother, Michelle Valdez, is twenty-four, with straight, dark waist-length hair and, behind studious glasses, eyes made up like Cleopatra. She told me recently that the problem had started in August, when the family moved into a new house, a pale-yellow stucco rental in Calexico, about thirty miles south of the Salton Sea. “The houses in this area catch a lot of dirt,” she said—from the cars on the heavily trafficked road nearby, from the grass that the landlord insists on mowing, from neighboring Mexicali, the polluted city of a million just across the Mexican border, and, most of all, she said, from the farm fields throughout the valley. “We are in a hole here,” she said. “All the nasty stuff just sits in it.”

In September, the cough came and didn’t let up for two weeks. “Morning, afternoon, evening, it was cough, cough, cough,” Valdez said. Axel missed school, and his throat got so swollen that he could barely eat. He became a regular at the emergency room. Valdez and her husband, Antonio Marron, plied Axel with cough syrups, drops, Claritin—they’d been told he had allergies—and when those didn’t work they contemplated taking him to Mexicali for an herbal cure. “I was very desperate,” Valdez said. The medicines were also putting pressure on their finances. At the time, Marron was making about two hundred dollars a week working at Best Buy; Valdez stayed home, taking care of Axel and his sister, Ana, who is three.

One windy, cold morning in September, Axel told his mother that his chest hurt and he couldn’t breathe. Marron covered Axel’s face with a blanket and took him to the emergency room again. His lungs were swollen and full of mucus. This time, Marron was told what the family had already begun to suspect: Axel had asthma. At the hospital that day, they met a nurse, Aide Fulton, who runs the Imperial Valley Child Asthma Program. She began to educate them about how to manage a chronic condition in an environment seemingly designed to aggravate it.

Around the same time, Valdez had an episode herself, a tightening in her chest that felt as if someone were squeezing her with a belt. She went to the hospital, and learned that she’d lost a quarter of the capacity of her right lung. The diagnosis was chronic obstructed pulmonary disease, a condition associated with lifelong smoking. Valdez, who is not a smoker, has a genetic predisposition to C.O.P.D., but this was her first experience of it. She said, “I told my husband, ‘I never had an attack until you brought me here!’ ” Not that Marron has been spared. His current job, installing alarm systems, has him in and out of doors all day, and he recently came down with an infection in his lungs.

The valley is eighty per cent Latino and mostly poor. It also has the state’s highest rate of asthma-related hospitalization for children. The Imperial Valley Child Asthma Program is the only free asthma-education program in the county, and it operates on an average budget of a hundred and forty-six thousand dollars a year. Fulton told me that in the past few years there has been an increase in referrals from the towns adjacent to the Salton Sea. (At one school, in the seaside town of Calipatria, sixty-five children are ill.) “We already have an unmet need,” she said. “What are we going to do when the Salton Sea dries out?” She is thinking of her clients, and she is thinking of herself. Her husband has asthma, her oldest daughter has asthma, and, after twenty-five years in the valley, she has it, too. “The issue of the sea is a bomb,” she said. “It’s a monster coming to get us all.”...

I've been following southwestern drought issues for years. Dozens of millions of us in the region are at increasing risk across a variety of fronts -- including health.

Started posting about the drought when I lived in Vegas. See my post "Las Vegas: The next Anasazi Ruin?"

I recently updated the Excel sheet I've long kept to track the inexorably declining water levels in Lake Mead.

The all-time high water level of Lake Mead came in July 1983 at 1,223 feet above sea level. It has dropped some 145 vertical feet since then. That is a lot of water. The Colorado River Rocky Mountains watershed source snowpack has been steadily declining for decades. The Sierra Nevada watershed snowpack, source of California's hydrological cycle water, hit an all-time low this year.

UPDATE

 

'eh?

It's a southwestern US crisis writ large, but, California, with its 39 million population and huge economy is Ground Zero.

California snowpack survey canceled: 'Drought is severe'

State water officials had planned to make the trek back to the Sierra Nevada in the coming days to conduct their snowpack measurement Friday.

But Thursday they announced they wouldn’t bother. For the second consecutive month, there won’t be any snow to measure.

“This is just another piece of information in a series of increasingly dismal findings,” said Department of Water Resources spokesman Doug Carlson. “It nails down that the drought is severe – maybe as severe as any in our history.”

The latest disappointing news comes a month after Gov. Jerry Brown stood on a field at Phillips Station – where this week’s manual measurement was to occur – and announced California’s first mandatory statewide water use cuts to combat the ongoing drought. It was the only April 1 survey since 1941 without any snow.

Officials say conditions have gotten even worse since then. 

Though the manual measurement east of Sacramento often provides a backdrop for media coverage, the state uses electronic sensors up and down the Sierra to measure the water content of the snow. Snowpack accounts for about 30% of the state's water supply when it melts in the late spring and summer and replenishes reservoirs.

On April 1, statewide measurements showed that the snowpack’s water content was just 5% normal for that date, the lowest in records going back to 1950. Thursday’s readings indicate the snowpack’s water content is half an inch or about 3% of normal for this time period...

The Political Opportunity of a Drought
California Governor Jerry Brown's push for massive cuts to greenhouse-gas emissions turns a crisis into an opportunity to legislate.

“I can tell you, from California, climate change is not a hoax," California Governor Jerry Brown told Martha Raddatz earlier this month. "We’re dealing with it, and it’s damn serious.”

The key word missing from Brown's widely disseminated Sunday morning show soundbite was "drought." While his appearance on This Week was ostensibly meant to be about California's worst-ever drought on record, he parlayed the segment into a broader conversation about climate change.

With alarming reports about water shortages and the state's warmest-ever winter, Brown has successfully folded the issue of the drought into a broader slate of ambitious environmental reforms. But even as he puts together billion-dollar relief packages and labels climate-change opposition "immoral," he does so without explicitly linking the drought to global warming.

Even though reports from agencies like the National Oceanic and Atmospheric Administration have refrained from laying the historic drought at the foot of global warming, Brown has used the general sense of crisis to move ahead on climate-change issues. Brown's efforts are not only affecting California, but the rest of the country as well.

In an executive order on Wednesday, Brown called for the most aggressive cuts to carbon emissions in North America. The order establishes that California "must cut the pollutants to 40% below 1990 levels by the year 2030, more than a decade after he leaves office," the Los Angeles Times reported.

“California is taking the most aggressive steps to deal with pollution and the effects of climate change,” he told a roaring crowd at a climate-change conference in California.

As Bloomberg notes, in order to achieve this new target, the state will have to "require utilities to get more electricity from low-pollution sources, compel industries to cut smokestack emissions further and encourage greater numbers of cleaner cars on roads." One likely upshot is that California's efforts are going to impact businesses and utilities in other states, making the Golden State's policy a meaningful factor elsewhere in the country...

How will all of this affect human health? What will happen if/when the stream runs dry? We may begin finding out in relatively short order.

"What will California sacrifice to survive the drought?"

Poor people? Their livelihoods, their health? Remember, “When it comes to health, your zip code matters more than your genetic code.”

Another adverse health consideration linked to protracted drought? Elevated rates of  severe, widespread wildfires and the environmental (and respiratory) damage they cause. Below, estimate 2015 wildfire rate increases.

IN OTHER NEWS

California's Drought Has Killed Over 12 Million Trees In The Last Year

California's historic drought is having a major impact on the state's forests.

According to an aerial survey conducted last month by the U.S. Forest Service, approximately 12 million forest trees have died in Southern California and the southern Sierra Nevada mountains over the last year. The report credits unusually high temperatures, a diminished snowpack and a severe lack of rainfall with drying up the trees, leaving the region susceptible to forest fires.

Of the more than 4.2 million acres surveyed in Southern California, researchers found 164,000 acres with high tree mortality. They found approximately 2 million trees had died over the last year.

In the southern Sierras, researchers found over 10 million perished trees in 4.1 million acres. There, mortality is "widespread and severe" in the foothills among ponderosa, gray pine, blue oak and live oak trees.

Jeffrey Moore, the acting aerial survey program manager for the region, told the Los Angeles Times he expects the mass tree mortality to continue throughout the summer...

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UPDATE

California drought: Can railroads come to the rescue?
CNBC: Jeff Daniels, @jeffdanielsca

As California's four-year drought worsens and water supplies dwindle in the state, an old technology—railroads—could play a role in alleviating some water shortages.

"We certainly have that capability today," said Mike Trevino, a spokesman for privately held BNSF Railway, which operates one of the largest freight railroad networks in North America. "We carry chlorine, for example. We carry liquefied commodities."

Experts say the East Coast's plentiful water could cost cents per gallon to Californians and provide a stable, potable water supply for small communities. Obstacles include identifying a state willing to share some of its water, and securing the construction funds for key infrastructure work, including terminals that can handle water...

 Yeah. I was on that years ago.

From the CNBC article:

"Experts say the East Coast's plentiful water could cost cents per gallon to Californians and provide a stable, potable water supply for small communities."

That is simply not true, at least in the sense that the "cents per gallon" assertion is meant to imply that the cost would be trivial, consequently making large-scale rail water transport economically viable. An acre-foot of water weighs 1390 tons. This acre-foot would fill 10 of the largest DOT-100 rail tank cars, each of which has a tare (empty) weight of 62 tons. At the usually cited 5 cents per ton-mile rail freight transport cost, you're looking at $100 per mile per acre-foot. Forget the "east coast." Assume, for the sake of illustrative argument, that you could drop a "straw" into Lake Superior (with its massive 2,903 cubic miles of water) -- at, say, Duluth -- pump it into rail tank cars and transport it ~2,000 miles to parched California. (Those living around Lake Superior would never miss it, but they'd invariably Primal-Scream howl that the exporters were going to drain the lake dry for the benefit of San Joaquin Valley walnut growers and other SoCal billionaires.)

I get 62 cents per gallon just for the transport.

Even were we to, say, alternatively route such hypothesized RR water tankers to the headwaters of the Colorado River Watershed northwest of Denver, up just past the Continental Divide (about 1,100 miles from Chicago or Duluth) to then discharge the water into the headwaters streams for subsequent gravity-borne southwestward downhill flow, you're still talking perhaps 32 cents per gallon (and you'd lose a bunch of it to evaporation across the rest of the journey).

Other issues: the states of Michigan, Wisconsin, and Minnesota, as well as (most importantly) the nation of Canada are unlikely to say "yeah, sure, by all means, help yourselves." Even moving the "straw" loading terminal south to Lake Michigan might not take Canada out of the policy picture (given the zero-sum fungibility of water), and would add ticked-off locals residing in Illinois and Indiana to the "not-in-my-backyard" states-level fray.

Moreover, there are only an estimated 300,000 DOT-111 rail tank cars in the north American freight market standing stock inventory, hauling every imaginable liquid commodity. While the image of a "rolling water pipeline" might present an alluring visual, it seems impractical to me at requisite scale. California alone consumes an estimated 8.5 million acre-feet of water per year. 10 rail cars per acre-foot? Do the math.

One tough problem.

CODA

Interesting "Seawater Desalination" post by the San Diego County Water Authority.

Outside-the-Box Afterthought on Desal

Two inherent liabilities of desal are [1] intense power consumption and [2] the brine effluent. Related to the first concern are the environmental impact of burning dirty extractive fuels to generate the electricity for the reverse osmosis process.

OK, rotate two of our ten nuke carriers in and out of station offshore (one off the northern coast, one off the south) to provide desal energy (far enough offshore to effectively mitigate the brine concentration problem on land), pumping the water into conventional tankers for subsequent distribution. Typical long range tanker ship capacity is about 20 million gallons (61 acre-feet).

The Navy could still do their routine training ops while powering desal production.

Gets around the problems of dirty hydrocarbon fuels emissions, prohibitive civilian nuke plant licensing obstacles, and ground-based nuke plant California earthquake concerns.

I know. Crazy.

Whatever. There are no cheap solutions. Cheaper than the socioeconomic (and broader misery index) upshot of a new dustbowl, though.
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MAY 8TH UPDATE

'It's Gone' — Snowpack Crucial for West's Water Melts Early http://t.co/9WEDDzuyR5 via @NBCNews #drought #CaliforniaDrought #drought2015

— Bobby Gladd (@BobbyGvegas) May 8, 2015

_____________ AnthropoceneDenial

More to come...

"Medical High School"? What?

Not kidding. I'm relocating from Las Vegas to the Bay Area. My wife works in Walnut Creek. Been a hassle for the past 5 years, this now-concluding "Virgin America Marriage" (and back to a real one). We're selling our Las Vegas house. The truck will be here on Sept. 13th.

Found a great, spacious place to lease out in Antioch ("Good Antioch," as the locals say, the south side). I can even bring my digital baby grand! Only about 17 miles or so from Cheryl's office, no freeways to contend with.

Looks like a "Bubble-icious" area to me, in light of the surplus of relatively inexpensive rents out that way. I'm gonna pay half what I'd have paid in Walnut Creek proper. This had to be one of those locales that got quickly built up all shiny and new and was subsequently populated by a lot of incautious buyers who took out pricey ARM loans and bought high, only to crash unceremoniously and painfully back to earth when the economy tanked about 5 years ago (my fav acronym of the era is the "NINJA Loan" -- No Income, No Job, or Assets).

So, I'm surfing the ZIP 94531 area on Google Map last night, zooming in and out, scrolling up and down, panning left and right, when I run across this maybe a mile away from our new digs: "Dozier-Libbey Medical High School." What?

Indeed. Wow.

They call it a "pathway school." Below, sort of their Mission/Vision Statement.

What's not to love? Get to 'em early. I've reached out to this school to offer to be a volunteer in any appropriate manner they might see fit to use me. I bet the kids that go to this school are really bright, really teachable. I'll have the schedule flexibility.

We'll see. They're probably wondering "who the heck is this guy?"

How nice. This is an idea that should spread nationwide, in light of the severe and growing need for astute people in every aspect of health care.

apropos, my Rolling Stone email newsletter popped into my inbox a little bit ago, and had a link to this:

Jerry Brown's Tough-Love California Miracle
The 75-year-old governor rescued the Golden State from financial ruin - and is reshaping a national progressive agenda

...Just two years ago, the idea that California could be a global model for anything was laughable. When Brown took office, the state was staggered by double-digit unemployment, a $26 billion deficit and an accumulated "wall of debt" topping $35 billion. California was a punch line for Republican politicos – a cautionary tale, they said, of the fate that awaits the nation should it embrace Left Coast-style economic, social and environmental liberalism. On the campaign trail in 2012, Mitt Romney joked that "America is going to become like Greece, or like Spain, or Italy, or like . . . California."...

he California that Brown inherited on his return to office appeared to be an insolvent, ungovernable mess. California's finances have been out of wack since the late 1970s, when right-wing, anti-tax activists passed Prop 13, a constitutional cap on property taxes that also requires a two-thirds supermajority vote to raise any tax through the state legislature. Moreover, it was a Republican, Arnold Schwarzenegger, who hastened the recent fiscal calamity by slashing California's vehicle license fee. Promising to cut the "car tax" keyed Schwarzenegger's victory over the hapless Democrat Gray Davis in the recall election of 2003. But it also blew a $4 billion annual hole in the budget that Schwarzenegger simply papered over with bond debt.

When the Great Recession struck and the state's credit rating collapsed, California was in a bind: Its budget shortfall was too massive to resolve with cuts alone. But the state's intransigent minority of Republican lawmakers refused to raise revenues. Making matters worse, in the same 2010 election that returned Brown to office, Californians tied his hands by approving another hard-line anti-tax proposition that reclassified many state fees as "taxes" and even made closing tax loopholes subject to supermajority rules...

HEALTH CARE
Curbing climate pollution is just one way Brown is working to breathe new life into the ambitious agenda President Obama pursued in his first term. The nation's most populous state is also leading the country in the implementation of Obamacare – providing a critical test case that a model pioneered in Massachusetts can work, at scale, in a massively diverse state where nearly one in four residents lacks health coverage. "It's not too much to say that the success or failure of California will determine the fate of the legislation going forward," says Tanden, who helped craft Obamacare as a senior administration adviser. "I believe it will be a success – they're way ahead of everyone."

In June, Brown signed legislation adopting Obamacare's generously subsidized expansion of Medicaid to the working poor. Ever budget-conscious, Brown had been wary of the "big costs" and "big unknowns" of growing a program that already accounts for 20 percent of the state's general fund. But unlike GOP governors – such as Perry in Texas – who have rejected the program out of hand, Brown pragmatically embraced the challenge and the opportunity to cover 1.4 million state residents. "We're going to move with commitment," Brown said, "because I do believe people do need decent health care."

California also made headlines this spring when it unveiled sample rates for individuals in its new insurance exchange, which will serve up to another 5 million residents. Many had predicted sticker shock as premiums adjusted to cover Obamacare's expanded benefits. Instead, the increases were modest and plans affordable. Even before federal subsidies, 25-year-olds can get coverage for $141 a month; 40-year-olds for $219. The system is working, health advocates say, because California used its bargaining power to force insurers to offer uniform products and compete on price. "We held insurers' feet to the fire," bragged Peter Lee, the governor's executive director for California's insurance exchange...

EDUCATION
Having waged and won his 2012 ballot initiative by focusing on education funding, Brown is now transforming how that money gets spent. The governor's new budget begins by restoring school districts to their pre-recession funding. But it targets additional spending for districts with high concentrations of at-risk learners. "A child in a family making $20,000 a year or speaking a language different from English requires more help," Brown said, pitching the plan to the legislature. "Equal treatment for children in unequal situations is not justice." Of the state's 6 million public schoolchildren, 3 million come from homes that don't speak English. Two million live in poverty. Under the new formula, per-pupil funding in Fresno – a city in the agricultural Central Valley, where 92 percent of students are disadvantaged – will nearly double by 2020 to more than $12,000.

U.S. Secretary of Education Arne Duncan and Brown have clashed on policy in the past, with Brown decrying federal testing regimes that force students to regurgitate "quiz bits of information." But in June, Duncan praised Brown's "real courage" for implementing a reform that may sound like "common sense" but – given how America's schools have historically been funded – "is actually revolutionary."...

I'm glad to be "coming home" to California after 45 years. I was born in NY, raised in NJ and first came to CA in 1966, and then lived in North Beach San Francisco in 1967-68. I have never felt so at home anywhere else (I'm gonna be a BART-ridin' fool; oh! the reading I'm gonna get done).

Yeah, the state has huge problems. So what? See "How Jerry Brown Scared California Straight" and "Jerry Brown's Political Reboot."

On the topic of medical education, the latest lament over at ScienceBasedMedicine.org

The Trojan Horse called Integrative Medicine arrives at another medical school
Posted by Scott Gavura on August 29, 2013

Medicine is a collaborative practice. Hospitals are the best example, where dozens of different health professionals work cooperatively, sharing responsibilities for patient care. Teamwork is essential, and that’s why health professionals obtain a large part of their education on the job, in teaching (academic) hospitals. The only way that all of these different professions are able to work together effectively is that their foundations are based on an important, yet simple, principle. All of us have education and training grounded in basic scientific principles of medicine. Biochemistry, pharmacology, physiology – we all work from within the same framework. As a pharmacist, my role might include working with physicians and nurses to manage and monitor medication use. A team approach is only possible when you’re working from the same playbook, and with the same aim. And in medicine, that playbook is science.

That’s why “integrative” medicine frightens me so much. Integrative medicine is a tactic embedding complementary and alternative medical practices into conventional medical care. Imagine “integrating” a practitioner into the health system that doesn’t accept germ theory. Or basic disease definitions. Or the effectiveness of vaccines. Or even basic biochemistry – perhaps they believe in treatments that restore the body’s “vital force” or manipulate some sort of “energy fields”. Instead of relying on objective signs and symptoms, they base treatments on pre-scientific beliefs, long discarded from medicine. There may be entirely different treatment goals, which are potentially antagonistic to the scientific standard. Imagine a hospital or academic setting where this occurs, and the potential impact on the quality of care that is delivered...

"There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is “Eastern” or “Western,” is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest. We recognize that there are vastly different types of practitioners and proponents of the various forms of alternative medicine and conventional medicine, and that there are vast differences in the skills, capabilities, and beliefs of individuals within them and the nature of their actual practices. Moreover, the economic and political forces in these fields are large and increasingly complex and have the capability for being highly contentious. Nonetheless, as believers in science and evidence, we must focus on fundamental issues—namely, the patient, the target disease or condition, the proposed or practiced treatment, and the need for convincing data on safety and therapeutic efficacy." - Phil B. Fontanarosa & George D. Lundberd "Alternative Medicine Meets Science, JAMA

...In the science-based, reality-based world, there is no yang that needs to be fortified, just as there is no such thing as a yin deficiency. Yet your licensed TCM practitioner can sell you horny goat weed which is Health Canada approved to treat your forgetfulness and cold lower back. And if the University of Toronto is successful with its new Centre for Complementary and Integrative Medicine, this type of material may soon be “integrated” into its medical and pharmacy education. The entire concept is absurd...

Conclusion
Moves to embed CAM into academic settings start with the assumption that “integrative medicine” is a good thing, in the absence of any data to show that is the case. Based on the information that does exist, it’s reasonable to assume that increasing the levels of “integrative” medicine at the University of Toronto will reduce and compromise the quality of medical and pharmacy education, and ultimately, the quality of care offered to patients. It’s sadly ironic that the University of Toronto, with a medical school lauded by Abraham Flexner in 1910, is now turning its back on those qualities, 103 years later.

 At Dozier-Libbey Medical High School, an emphasis on "science" is touted.

Would controversies pertaining to "integrative medicine" be a topic for senior "Medical Ethics"?

SPEAKING OF HEALTH

Just in, from The NY Times:

Ugh. My grandson Keenan is now a sophomore at St. Olaf College. He plays football. Loves it. Loves to hit and be hit. We worry about brain damage.
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A PHYSICIAN ASKS "WHY BUILD MY OWN EMR?"

A doctor takes up the Fred Trotter challenge. "Why re-invent the EMR wheel? ... Here’s my answer to that question"

What medical records offer: High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.

What I need: No focus on billing codes, instead a focus on workflow.

What medical records offer: Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit.  It results in massive over-documentation and obfuscation of pertinent information.

What I need: Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.

What medical records offer: Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)

What I need: Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.

What medical records offer: Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.

What I need: A collaborative record, sharing most/all information with patients so they can use it in other settings for their care. Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.

What medical records offer: Organization of information is not a high priority, as physicians are not reimbursed for organized records. The main focus is instead on meeting the “meaningful use” criteria, which gives financial incentive to physicians who use a qualified record system.

What I need: Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial. The goal is to put the most important information up front and to give easy access to the details sought.  I am the “curator” of the record, organizing it and prioritizing information in a way that is useful to both me and my patients.

What medical records offer: Top priority is paid to billing workflow, with second billing given to in-office patient management.  The least attention is given to clinical workflows for patients outside of the office.

What I need: My priorities are 180 degrees from this. My top priority is keeping people outside of the office healthy and happy. which will keep them paying their monthly payments), so maximizing organization and communication need to be the focus of my records.  Certainly in-office care needs to be efficient, but not in the same way as the rest of the healthcare system (efficient documentation for payment); it must focus on getting the most accurate information into the system and making it easiest to get information out.  Billing is almost a non-issue, as it is very simple in my system.

What medical records offer: Task management is again a low priority, as it increases potential non-reimbursed work for physicians (and staff) in the typical office.  For example, there is not much emphasis put on phone office follow-up or making sure the plan is communicated to the patient.  This is not strictly avoided, as most medical professionals do want to give good care, but the high-stress overworked atmosphere in most offices makes most medical personnel reject any tool that gives “extra work.”

What I need: Task management is near to the top. I am focused on coming up with a care plan for each patient and making sure the patient understands that plan.  The goal is to reduce the chance of misunderstanding, as it increases my work and decreases the patient’s chance for health.  So an integrated task-management tool is very important, as is education resources which can be accessed directly from the patient record and given to the patient to keep (ideally) in an online “folder.”

What medical records offer: Mobile communication is becoming more available, but it is very much system centric., meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.

What I need: My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end.  I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application).  I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible.  In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.

What medical records offer: Payment for health services generally depends on two things: a problem being treated and a procedure code and are therefore the focus of the record system.  Problem lists are in the record, not primarily because they help with care, but to allow billing for services.

What I need: I believe we should focus far more on reducing risk factors than on treating “problems.” My goal is to avoid problems and do fewer procedures when and where at all possible.  Problem lists should not be focused on code, but instead to give the most accurate information to lead to the best decisions, and to help understand the risks the patient faces so problems can be avoided.  If this happens, I will have less procedures, a fact that will make both me and my patients happy.

What medical records offer: Optimistically, the ultimate goal of the typical EMR is to allow a physician to practice the best medicine possible while not going out of business. It allows physicians to give good care despite the system that rewards them for bad care.

What I need: The goal of my record system is to promote the success of a new business model: pay doctors more to keep people well and to keep people out of the rest of the health care system. The ultimate goal of this record system is not to make money for me as software I can sell, but to make it so I can extend the model efficiently to a larger population, ultimately making this new system of care an attractive enough alternative to physicians, employers, and patients to make the switch.  Perhaps in doing so the “do more, spend more” system can be replaced by a welcome alternative.

Dr. Rob is a good guy. I follow his blog posts routinely. He recently went "direct pay" -- cash subscribers. No 3rd party billing (the still-principal focus beef against mainstream EMRs, i.e. "ONC certified" EMRs).

HIX UPDATE

Aug 29 (Reuters) - Aetna Inc has decided not to sell insurance on New York's individual health insurance exchange, which is being created under President Barack Obama's healthcare reform law, the fifth state where it has reversed course in recent weeks.

The third-largest U.S. health insurer has said it is seeking to limit its exposure to the risks of providing health plans to America's uninsured, but did not give details about its decision to pull out of specific markets.

"We believe it is critical that our plans not only be competitive, but also financially viable, in order to meet the long-term needs of the exchanges in which we choose to participate. On New York, as a result of our analysis, we reluctantly came to the conclusion to withdraw," Aetna spokeswoman Cynthia Michener said...

Wonder how this will affect NY's newly approved "Oscar" HIX (if at all)?

ERRATUM

An interesting aspect of packing up to move after being in Vegas for 21 years is running into long-forgotten items, such as papers and reports written long ago. The snip below is from a series of reports I wrote 20 years ago during my first HealthInsight tenure (then called "Nevada Peer Review") based on analyses of what were then called "HCFA data" -- basically large file dumps of Medicare claims data that included HIC numbers, demographic info, facility IDs, Attending IDs, admit and discharge dates, discharge destinations, admitting dx, principal dx, secondary dx's, px/tx codes, DRGs, etc.

A hot topic in those days was the "30-day readmit," patients discharged and then re-admitted to an acute care facility within 30 days -- a possible marker for poor quality care.

(The data were crunched and graphics rendered in Stata.)

20 years later, a priority topic for HHS/CMS study and improvement action under the PPACA "pay-for-performance" initiatives (P4P)? The ever-so-persistent "30 Day Readmission."

Maybe this time, given the significantly increased availability of EHR-borne clinical data supplanting claims data, we'll finally make some headway.

PDF scan copy of these ancien reports here (~18 mb. I omitted the voluminous tables).

SPEAKING OF DATA

Bloomberg has an interesting interactive presentation up:

Overview
Bloomberg ranked countries based on the efficiency of their health-care systems.

Methodology
Each country was ranked on three criteria: life expectancy (weighted 60%), relative per capita cost of health care (30%); and absolute per capita cost of health care (10%). Countries were scored on each criterion and the scores were weighted and summed to obtain their efficiency scores. Relative cost is health cost per capita as a percentage of GDP per capita. Absolute cost is total health expenditure, which covers preventive and curative health services, family planning, nutrition activities and emergency aid. Included were countries with populations of at least five million, GDP per capita of at least $5,000 and life expectancy of at least 70 years.

I snipped out the top and bottom 10.

Not sure yet how I feel about these summary proxies for "efficiency." Do what degree do they reflect "quality"? And, if we define "value" as "Quality/Cost," can we get there from these data?

Dubious.

SPEAKING OF HEALTH DATA

I just downloaded this from O'Reilly (free with registration).

...[D]ata and predictive analytics have driven ever deeper in­ sight into user behavior such that companies like Google, Facebook, Twitter, and LinkedIn are fundamentally data companies. And data isn’t just transforming the consumer Internet. It is transforming fi­ nance, design, and manufacturing—and perhaps most importantly, health care. How is data science transforming health care? There are many ways in which health care is changing, and needs to change. We’re focusing on one particular issue: the problem Wanamaker de­ scribed when talking about his advertising. How do you make sure you’re spending money effectively? Is it possible to know what will work in advance?

Too often, when doctors order a treatment, whether it’s surgery or an over-the-counter medication, they are applying a “standard of care” treatment or some variation that is based on their own intuition, ef­fectively hoping for the best. The sad truth of medicine is that we don’t always understand the relationship between treatments and out­ comes. We have studies to show that various treatments will work more often than placebos; but, like Wanamaker, we know that much of our medicine doesn’t work for half of our patients, we just don’t know which half. At least, not in advance. One of data science’s many promises is that, if we can collect enough data about medical treat­ments and use that data effectively, we’ll be able to predict more ac­curately which treatments will be effective for which patient, and which treatments won’t.

A better understanding of the relationship between treatments, out­ comes, and patients will have a huge impact on the practice of medi­cine in the United States. Health care is expensive. The U.S. spends over $2.6 trillion on health care every year, an amount that consti­tutes a serious fiscal burden for government, businesses, and our so­ciety as a whole. These costs include over $600 billion of unex­plained variations in treatments: treatments that cause no differ­ences in outcomes, or even make the patient’s condition worse. We have reached a point at which our need to understand treatment ef­fectiveness has become vital—to the health care system and to the health and sustainability of the economy overall.

Why do we believe that data science has the potential to revolution­ize health care? After all, the medical industry has had data for gen­erations: clinical studies, insurance data, hospital records. But the health care industry is now awash in data in a way that it has never been before: from biological data such as gene expression, next-generation DNA sequence data, proteomics, and metabolomics, to clinical data and health outcomes data contained in ever more preva­lent electronic health records (EHRs) and longitudinal drug and med­ical claims. We have entered a new era in which we can work on massive datasets effectively, combining data from clinical trials and direct observation by practicing physicians (the records generated by our $2.6 trillion of medical expense). When we combine data with the resources needed to work on the data, we can start asking the impor­tant questions, the Wanamaker questions, about what treatments work and for whom.

The opportunities are huge: for entrepreneurs and data scientists looking to put their skills to work disrupting a large market, for re­ searchers trying to make sense out of the flood of data they are now generating, and for existing companies (including health insurance companies, biotech, pharmaceutical, and medical device companies, hospitals and other care providers) that are looking to remake their businesses for the coming world of outcome-based payment models...

Yeah, to be sure. But, still, I worry about naive and slovenly analytics of "Big Data."
___

More to come...

Looking back, taking stock

The REC Blog is nearly 4 years old. A labor of love. The name will soon be changing.

I just screen-scraped my "Blog Archive" links column to take a quick look back. It's about 2 books worth of content. Dang. One of my REC colleagues once asked "dude, when do you sleep?" 

I hope I've added some value to the #Health IT and #healthcare ferment. Sometimes, the more I study, the more I'm aware of how little I know. There is just so much to learn.

Eyeballs deep in several books these days. Working on finishing my own book. Working on some other stuff I'm not prepared to announce just yet. Woodshedding my guitar with a vengeance. That is great fun.

Itching to actually build some stuff, too. Been a "knowledge worker" for my entire white collar career. Building some physical products would be a nice change. I have several ideas.

Loving just living, too, being back with my amazing wife, my best friend of 40 years, after 5 difficult years of work separation. I am one lucky man.

Thanks to all of you that keep stopping by my little pro bono lone-wolf shop. Lots more to come.
__

The Blog archive to date.

▼  2014 (34)
▼  March (11)

• Mapping EHR penetration, 2013
• Excellent new paper from Nuance
• Issues with Comparative Effectiveness Research
• Aye...
• 'An EHR should not be a federally-subsidized “hard...
• #HealthIT 2014?
• Chuck Webster's "Pragmatic Interoperability," cont...
• “Predictalytics”?
• "Transparency" games? Are heart surgeons cherry-pi...
• "Your smartphone will see you now"
• This is brilliant

▼  February (14)

• #HIMSS14 Day Four
• #HIMSS14 Day Three
• #HIMSS14 Day Two
• #HIMSS14 Day One. And, off we go...
• “We should not prescribe specific functionality fo...
• #HIMSS14 - Let's ROLL!
• ONC - REC Spin Cycle 101?
• ROI - Health IT Return On Investment 101
• Up next: #HIMSS14
• “In wellness, you don’t have to challenge the data...
• īˈkänəˌklast
• Meaningful Use 2013 review, ONC Working Group Stag...
• Health Affairs TeleHealth Conference
• KatrinaCare.gov update

▼  January (9)

• "There is no way to survive the coming rise in Med...
• "The SOTU is ____________________________."
• BREAKING: Nevada State Health Information Exchange...
• “When it comes to health, your zip code matters mo...
• Meaningful Use Stage 2 is off to a bumpy start
• Next up...
• The Society for Science Based Medicine
• Meaningful Use Stage 2 now fully underway
• Happy New Year to everyone in Health IT

▼  2013 (127)
▼  December (10)

• Holiday respite
• ICD-10: W6142XA, Struck by turkey, initial encount...
• More #IHI25Forum
• A sad anniversary
• #IHI25Forum Updates
• #IHI25Forum Monday Dec 9th
• #IHI25Forum Day One - Preconference
• Off to #IHI25Forum
• Philosophia sana in ars medica sana
• December 2013: a busy month ahead

▼  November (13)

• A Thanksgiving weekend blogging respite
• Buckshot: the continuing randomness of U.S. health...
• "He never met a vegetable he didn't hate"
• Let's Go Nuts!
• Healthcare "Big Data" will not be a panacea
• NYeC 2013 Digital Health Conference Day Two
• NYeC 2013 Digital Health Conference Day One
• Off to the Big Apple
• One in Three
• Next up: the NYeC Annual Digital Health Conference...
• The ASC X12 834 005010X220/005010X220A1 Lonesome H...
• HealthCare.gov: Nobody Got The 2010 PPACA Memo?
• (404)^n, the upshot of dirty data

▼  October (11)

• KatrinaCare?
• HealthCare.gov in the Congressional crosshairs
• DATA: Meaningful Use Attestation and 2014 CEHRT up...
• Federal default averted for now, time to fix the H...
• Shower the people
• Cusp of Convergence?
• ObamaCare HIX: let the Sticker Shock and Benefits ...
• Farzad's next chapter
• Health 2.0 2013 final day
• Health 2.0 2013, Day Two
• Health 2.0 2013 Day One. Lights, cameras, action!

▼  September (8)

• Health 2.0 EDU Day
• Amid the increasing din of negativity, a Singular ...
• HIPAA Omnibus: no more excuses, compliance date is...
• Back online in California
• 12 years ago today
• Headlines and deadlines
• California, here I come...
• Meaningful Use payments update through July

▼  August (10)

• "Medical High School"? What?
• Health IT down the drain
• Are you ready to board the Omnibus?
• HIX Update: here come the Oscars
• "Start Spreading The News..."
• Meaningful Use to become a "political football"?
• The future of the PPACA explained in one small jpe...
• ONC Chief Dr. Mostashari calls it quits
• The "Do Nothing Congress" heads home for six weeks...
• 54 Days and counting. Time to get on the Omnibus

▼  July (10)

• Meaningful Use Payments Update
• An EPIC Tale. Portending an EPIC Fail?
• Delay Stage 2?
• "20%" MU dropout rate? "17% dropout rate"?
• "RECs are well positioned to continue to assist pr...
• The Progress Principle and Meaningful "Use"
• Whither/"Wither" Meaningful Use?
• Happy Birthday, America
• Summer reading list
• July 1st, always a sad day

▼  June (8)

• Bad news for the Meaningful Use initiative
• Hiatus, briefly
• " It's not one-size-fits-all"
• Whither?
• SPC for Lean Newbies
• "Data flowing at the speed of trust"?
• Lean Healthcare Transformation Summit 2013
• Speaking of "Health Information Technology"...

▼  May (15)

• Massachusetts Law 2012.224.108
• If I knew then what I know now... pondering the Na...
• "If I knew then what I know now, what would I do ...
• How Fragile We Are
• Courage
• California State HIT Day
• Refactored Day 2
• "Refactored" - a jam-packed two days in Mountain V...
• Happy Mother's Day
• The Red
• "Transforming" Health Care?
• Reporting from Reindeer Mountain
• Health 2.0 Refactored 2013
• REC progress data release update from ONC
• Home again

▼  April (11)

• The fundamental problem facing health care policy
• Sweet
• "What happens when an eligible provider or eligibl...
• "REBOOT" report, continued
• Meaningful Use news update
• Aghast
• A new Day. BobbyG's REC campaign is moving to KHIT...
• Meaningful Use attestations thus far by vendor
• LYBBAVERSE: Repost by request
• Weekend update
• Blood on the tracks in Reno

▼  March (12)

• Hello from Walnut Creek
• HIT, meet HIX
• Figliozzi strikes again
• Health data flowing "at the speed of trust"
• HIE - "Bank" on it?
• "BOOM!"
• HIMSS13 Thursday March 7th
• HIMSS13 Wednesday March 6th
• HIMSS13 Tuesday March 5th
• Monday at HIMSS13
• WHAT? "Boil Water order" for NOLA?
• Off to NOLA!

▼  February (10)

• Austerity
• Obesity
• Countdown to HIMSS13 in NOLA
• #EHRbacklash?
• "Interoperability" - soon to be the #1 cliche of t...
• Flow, meet ebb?
• Cane toads and kudzu
• "The stage 1 criteria were theory-based. Stage 3 n...
• The REC Cafe du Monde Caucus in NOLA at HIMSS13
• Clinical workflow

▼  January (9)

• Hats off to Qualis' WIREC
• Meaningless Auditing of Meaningful Use
• Update from Walnut Creek
• HIPAA Omnibus Final Rule FINALLY released
• HIMSS13 New Orleans: March 3 - 7!
• Wiki Doc Resource: "The Living Textbook of Medicin...
• ARCH-IT website launched
• The Curious Case of the Missing Final Rule
• A 2013 Happy New Year to the HIT sector

▼  2012 (85)
▼  December (8)

• From the REC Blog, adieu 2012
• December 22nd updates
• Grief
• Ready, [bleep], Triple AIM!
• #ONC2012 #HealthIT #RegionalExtensionCenters
• G-A-T-C, meet SCOTUS
• December 7th, 71 years ago
• O HIPAA, Where Art Thou?

▼  November (9)

• HIT and the "Fiscal Cliff"
• Happy Thanksgiving to all
• RECs: don't get run over; you won't make the local...
• HealthInsight REC retreat
• "Big Data"? How about REALLY Big Data? "Personaliz...
• SERIOUSLY?
• Congratulations, President Obama
• The Future of Health IT
• "Obama Administration Sits on Key Regulations"?

▼  October (13)

• In the Federal Register Oct 31st: yet another heat...
• Fred Trotter at Strata Rx 2012
• Hurricane Sandy
• REC Blog post number 1100111
• Stayin' with the numbers: REC Brew 102
• REC Blog Milepost 101
• REC blog post 100
• Health 2.0 SF Final Day: From DC to VC
• Day 2 Health 2.0
• Day One Health 2.0, full on
• Sunday registration and pre-conference events
• Up next...
• Time for procrastinating is over, folks

▼  September (10)

• Au revoir, FY 2012. Bonjour FY2013
• Time to play nice
• The 2014 CEHRT 3rd Wave
• Weekend Updates
• "Savings promised by the government and vendors of...
• “Federal funding of IT was a step in the right dir...
• A sad anniversary
• Draft 2014 CEHRT Certification Testing Stds Issued...
• 45 CFR 164.308 and HIT vendors
• One month to go before risking missing the 2012 At...

▼  August (5)

• Single Source of Truth
• Stage 2 Final Rule and 2014 CEHRT Final Rule
• 2012 Meaningful Use Year One Attestation deadline ...
• Dog Days errata
• M&M's...?

▼  July (6)

• MCC Hammer
• Post MU incubation
• "The Health Care Handbook" considered
• Analytics - SAS, R, SQL, EHR database schema. An o...
• Primary care: renewal or exodus?
• A sad anniversary for me

▼  June (6)

• PPACA Upheld
• Tick, tick, tick...
• The Association of Regional Centers for Health Inf...
• ObamaScare Section 5405
• "Pruh-SEE-jer"
• Tangent: PPACA at the precipice

▼  May (4)

• 45.CFR.164.3, 45.CFR.164.5, and 42.CFR.2
• Two Years on...
• My first guest cross-post: "Personalized Preventio...
• Let a Thousand Flowers Bloom

▼  April (6)

• Policies and Procedures
• Just in case you thought OCR wasn't serious
• Oink
• Barriers and Brickbats and Opportunities
• Attestation money thus far
• The Imminent Storm?

▼  March (6)

• Three days of PPACA Orals
• The Jennings Moot Court tees up the PPACA
• PPACA Orals at SCOTUS, March 26-28
• Yet another federal public comment period announce...
• MU Stage 2 and 2014 CEHRT Public Comment Period th...
• Two years on...

▼  February (8)

• HIMSS 2012 reflections
• HIMSS 2012 Final Day
• Stage 2 and CEHRT 2014 announcements
• HIMSS 2012 Day 2
• HIMSS Day 1 quick random photo essay
• Welcome to Las Vegas, HIMSS12
• Greed? Ego?
• Back down in the Weeds'

▼  January (4)

• Oops
• Down in the Weeds'
• Shovel Ready
• 2012: ruminating on the year ahead in HIT

▼  2011 (32)
▼  December (3)

• The twisty politics of HIT
• Facts © ™ ®
• Meaningful Use Reimbursements Update

▼  November (2)

• So many topics and issues, so little time
• Blog Hiatus for a bit

▼  October (6)

• ACOs? "Another Crock of, uh, Government"?
• Telemetry (and other stuff)
• 2011 Nevada Health Care Forum, Oct 11th
• IF AIR TRAVEL WORKED LIKE HEALTH CARE
• My heart goes out to Steve Jobs' family and friend...
• National Health IT Hype Week, Sept 27th

▼  September (4)

• The only person who enjoys change is a baby with a...
• National Health IT Week, Sept 12 - 16
• September 11, 2001
• Another "Use Case"

▼  August (2)

• Talk Dirty to Me
• 2011 ONC Regional Conference in Hollywood
• ▼  July (2)
• What does "obtain consent" mean with respect to HI...
• Nevada HIE kickoff event

▼  June (3)

• Meaningful Manual Labor
• Use Case
• Meaningful Use ePHI Privacy and Security complianc...

▼  May (4)

• Meaningful Use, or meaningless "hoopla"?
• Health Policy Research: a promising new resource
• A year of REC blogging
• Athena Health CEO Jonathan Bush on the RECs

▼  April (2)

• Meaningful Use Attestation Day One, April 18th
• Springtime for Meaningful Use

▼  March (1)

• The Ides of our forced REC March

▼  February (2)

• Poof! Where did THAT year just go?
• Bottlenecks, bugs, barriers...

▼  January (1)

• 2011, Meaningful Use Stage I, Year I Showtime. Opp...

▼  2010 (6)
▼  December (1)

• My Excellent Adventure into the Mecca of Quality

▼  November (2)

• First, Do No "Hold Harmless"
• November 2010 updates

▼  October (1)

• Mulligan: 7.5 months into my REC adventure

▼  July (1)

• Game ON - Meaningful Use Final Rule issued

▼  May (1)

• Opportunity for collaboration? ASQ and the RECs

___

More to come...