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Sunday, October 16, 2011

Telemetry (and other stuff)

Corventis – "Can our bodies become wireless transmitters? The people at San Jose-based Corventis think so. Their Nuvant Mobile Cardiac Telemetry System can detect early heart arrhythmias using a small (2x6 inch) device mounted on a patient’s chest. This sensor sends a constant stream of data to a transmitter that then relays it to a monitoring center. It won FDA approval last year. Even more intriguing is work being done at the University of Illinois where ultrathin, electronic medical monitors are being designed that can be attached to a patient’s skin, like a tattoo..."

I'd already heard about the "tattoo" thing, and had meant to post about it. Getting difficult to keep up with everything; to wit,


Or, "Hot Spotters for nicer people." In the November Atlantic
ELLEN, AN 82-YEAR-OLD widow, lives in Anaheim, California. One Wednesday morning last year, she got on her scale, as she does every morning. One hundred and forty-six pounds—wasn’t that a little high? Ellen felt vaguely troubled as she poured herself a bowl of oat bran.

Half an hour later, the phone rang. It was Sandra at the clinic. She too was concerned about Ellen’s weight, which had jumped three pounds since the previous day. Sandra knew this because Ellen’s scale had transmitted its reading to the clinic over a wireless connection.

Given that Ellen had a history of congestive heart failure, a three-pound weight gain in 24 hours was a potentially dangerous development, a sign of possible fluid buildup in the lungs and increasing pressure on an already stressed heart. Sandra wanted her to come in for an immediate visit: the clinic would provide a car to pick her up and bring her back home. Ellen’s treatment began that very morning and continued for two weeks until she was out of danger. Had the warning signs not been noticed and addressed so quickly, she might easily have suffered a long, painful, and expensive hospitalization.

Dan, a retired letter carrier, is a patient at a clinic in the same system. At 87, he is decidedly frail, his once-sturdy legs now weak and unsteady. He is a classic candidate for a fall of the kind that has injured many of his friends, in some cases leading to weeks in the hospital and months of rehab. The elderly are prone to falls for many obvious reasons, including weak limbs, impaired vision, and medication side effects. But Dan’s doctors knew that some less obvious causes included shag carpets and long, untrimmed toenails. Because of this, they’d sent someone from the clinic to visit Dan’s apartment and make sure that his daughter replaced the 1980s-vintage carpets with low-pile rugs. Dan also visits the clinic regularly for light muscle-training sessions and periodic toenail clipping. Due to these preventive measures, Dan and his fellow clinic patients are one-fifth as likely as comparable patients elsewhere to suffer falls.

Joe, a 79-year-old diabetic, cut his foot when he banged it against a door. When it didn’t heal after a couple of days, he limped into the office of his family physician. After glancing at the cut, his doctor immediately sent Joe to a clinic in the same system as those that treated Ellen and Dan. For diabetics, even small cuts can be a serious matter: untended, they can become infected and contribute to an alarmingly high rate of amputation.
At the clinic, a nurse practitioner cleaned and dressed the wound, and told Joe she wanted to see him there in two days so she could inspect and treat it again—and two days after that, and two days after that, until it was fully healed. The clinic would arrange for transportation if needed. Thanks to the steady, regular care, Joe’s foot healed without any infection or threat of amputation.

Ellen, Dan, and Joe are all real people, though their names have been changed...

Interesting. Well, this is a good time to get around to the "tattoo telemetry" stuff as well.

Electronic 'second skin' blurs technology and biology

SALT LAKE CITY -- In the Aug. 12 issue of the journal Science, Ma (Jack) Zhenqian g of the department of electrical and computer engineering at the University of Wisconsin published a new scientific paper detailing a hair-thin electronic patch that adheres to the skin like a temporary tattoo. Actually, patches are a common way to deliver medications now, but the new patch looks more like a circuit board diagram and is loaded with electrical engineering firsts. The patch will soon replace medical monitoring equipment cables and some other devices, making them wireless, self powered and more accurate...

...Incorporating these devices in patches similar to tattoos would enable biological readings to be remote and unobtrusively recorded day and night, so important events such as a heart arrhythmia or a spike in blood sugar levels are sure to be noticed.

In a very real sense, it is like being able to have a tabletop doctor's office —including sensors, circuits and elements for drawing power and transmitting data — are stuck to the surface of a 30-micrometer- thick, breathable plastic sheet...
So, is there a waft of Creepiness Factor in all this (e.g., like GPS surveillance tracking of your cell phone or OnStar)?

Blueprint for Innovation Encouraging computerized medical device invention
Sandy Weinberg, Ph.D., Ronald Fuqua, Ph.D.

A patient swallows a computerized capsule, providing his physician with a series of images of the gastrointestinal tract. Another patient accesses the computer control on her wheelchair, which raises her to a standing position and follows a carefully designed exercise program to keep her legs from atrophying. A computerized “lab on a chip” provides toxicologists with a complete analysis series from a single sample...
Or, how about
ePetri: a Smartphone-Based Petri Dish
by STANLEY DARMA on Oct 6, 2011

...The culture is placed on an image sensor chip and the phone’s LED screen functions as a scanning light source. The ePetri device is then placed in an incubator, with the image sensor chip connected to a laptop outside the incubator through a cable. The image-sensor takes pictures of the culture, the data is sent to the laptop and so cultures can be monitored as they grow. The technique is apparently particularly useful in the imaging of cells that grow very close to one another.

Instead of using a large, heavy instrument, they now have a lightweight microscope providing high-quality images of cells. The ePetri is able to monitor the entire field, but can still zoom in on areas of interest within the culture. The research team sees many possibilities for their technology, such as drug screening and detection of toxic compounds. It could even provide microscopy-imaging capabilities for other portable diagnostic lab-on-a-chip tools. Right now the team is also working on a more comprehensive system that would include a small incubator, transforming the ePetri into a desktop diagnostic tool.

Makes your head spin, all these developments. I guess, beyond the technology issues ("accuracy and reliability," e.g., sensitivity, specificity, durability) is the business case at the provider of record destination. Will I get paid for having to examine and assess this looming on-call-all-the-time tsunami of data 24/7?


BOSTON – Physicians who once only grappled with learning the language of medicine must now also cope with a health care world that has turned hospitals into factories and reduced clinical encounters to economic transactions, two Beth Israel Deaconess Medical Center physicians lament.

“Patients are no longer patients, but rather ‘customers’ or ‘consumers’. Doctors and nurses have transmuted into ‘providers,’ Pamela Hartzband, MD and Jerome Groopman MD, write in the Oct. 13 edition of the New England Journal of Medicine.

“We are in the midst of an economic crisis and efforts to reform the health care system have centered on controlling spiraling costs. To that end, many economists and policy makers have proposed that patient care should be industrialized and standardized. Hospitals and clinics should be run like modern factories and archaic terms like doctor, nurse and patient must therefore be replaced with terminology that fits this new order.”

The problem, Hartzband and Groopman, note, is that the special knowledge that doctors and nurses possess and use to help patients understand the reason for and remedies to their illness get lost in a system that values prepackaged, off-the-shelf solutions that substitute “evidence-based practice” for “clinical judgment.”...

"...Now some prominent health policy planners and even physicians contend that clinical care should essentially be a matter of following operating manuals containing preset guidelines, like factory blueprints, written by experts.”...

Difficult, all of it. Click the title image above for the full BIDMC article. Click here for my prior musings on issues of clinical judgment, cognitive traps, and Dr. Groopman.


Click the graphic. Well worth your time.



(Uh, I think he's my Sup now)

Yeah, I hate those things.


Text Messaging Among Providers Prevalent Despite HIPAA Compliance, Security Concerns
By Kendra Casey Plank

A majority of physicians use the text messaging capabilities on their so-called smart phones to exchange information about patients with other health care providers, but doing so could be a violation of federal privacy and security rules, a health information technology firm executive said Oct. 17...

HIPAA Concerns
Adam Greene, an attorney with Davis Wright Tremaine LLP, explained to the webinar audience that the HIPAA Security Rule applies to all electronic protected health information and that the broad definition of PHI could apply to data contained in text messages.

For example, a text message between two treating physicians could be considered containing PHI if it includes admission or discharge date information that could lead to the identification of an individual patient. Similarly, a message between a doctor and patient could be considered PHI, and thus covered by HIPAA, if it indicated a treatment relationship, Green said...

Uh, OK, see the proposed "HIPAA Privacy Rule Accounting of Disclosures Under the Health Information Technology for Economic and Clinical Health Act." While inter-clinician text messages are surely not explicitly part of a "Designated Record Set," I wouldn't lean too heavily on that going forward.

to wit:
45 CFR 164.501: Designated record set means:

(1) A group of records maintained by or for a covered entity that is:

(i) The medical records and billing records about individuals maintained by or for a covered health care provider;

(ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or

(iii) Used, in whole or in part, by or for the covered entity to make decisions about individuals.

(2) For purposes of this paragraph, the term record means any item, collection, or grouping of information that includes protected health information and is maintained, collected, used, or disseminated by or for a covered entity.

Direct treatment relationship means a treatment relationship between an individual and a health care provider that is not an indirect treatment relationship.

You tell me. ePHI is ePHI. Doctors are "covered entities."


696 pages of light bedtime reading (PDF). For starters, I've indexed all pages citing "meaningful use," "certified EHR," "HIPAA," and "covered entit(ies)."

From Bloomberg:
Health Rules Prod U.S. Hospitals to Form Networks for Care
By Carol Eisenberg and Alex Wayne - Oct 20, 2011 1:12 PM PT

...The U.S. Department of Health and Human Services issued final rules today for so-called accountable care organizations for the elderly and disabled, a centerpiece of the health-care law designed to save as much as $940 million in three years. Savings would be shared between providers and the government.

Participants can keep more savings after reaching targets, and will need to meet about half as many quality measures as first outlined in March. The delayed rule marks a victory for hospitals, clinics and large doctors’ practices that have lobbied to alter draft regulations they viewed as too burdensome and financially risky...

Quality Standards
An ACO’s potential reward will depend on its performance on almost three dozen quality standards. Other changes include a flexible start date in 2012, providing a list of likely patients up front and expanding participation to include rural health clinics and organizations where specialists provide primary care. Health-care providers won’t be required to pay back the government if they don’t hit savings targets...

We shall see. Give that this is tied to the PPACA ("ObamaCare"), should SCOTUS strike down the PPACA over the "Individual Mandate" issue, the ACO piece goes down with the ship.

More to come...

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