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Tuesday, July 31, 2012

MCC Hammer


Saw this reported on MSNBC this morning. From the CDC's NCHS (pdf):
Studies suggest that the presence of multiple chronic conditions (MCC) adds a layer of complexity to disease management; recently the U.S. Department of Health and Human Services established a strategic framework for improving the health of this population. This report presents estimates of the population aged 45 and over with two or more of nine self-reported chronic conditions, using a definition of MCC that was consistent in the National Health Interview Survey (NHIS) over the recent 10-year period: hypertension, heart disease, diabetes, cancer, stroke, chronic bronchitis, emphysema, current asthma, and kidney disease. Examining trends in the prevalence of MCC informs policy on chronic disease management and prevention, and helps to predict future health care needs and use for Medicare and other payers...

These findings demonstrate the widespread rise in the prevalence of two or more of nine selected chronic conditions over a 10-year period. The most common combinations of chronic conditions––hypertension and diabetes, hypertension and heart disease, and hypertension and cancer––increased during this time. Between 1999–2000 and 2009–2010, adults aged 45–64 with two or more chronic conditions had increasing difficulty obtaining needed medical care and prescription drugs because of cost.

Growth in the prevalence of MCC was driven primarily by increases in three of the nine individual conditions. During this 10-year period, prevalence of hypertension increased from 35% to 41%, diabetes from 10% to 15%, and cancer from 9% to 11%, among those aged 45 and over. A limitation of this report is that it includes only respondent-reported information of a physician diagnosis; thus, estimates may be understated because they do not include undiagnosed chronic conditions.

Increases in the prevalence of MCC may be due to a rise in new cases (incidence) or longer duration with chronic conditions. The prevalence of obesity—a risk factor for certain types of heart disease and cancer, hypertension, stroke, and diabetes—increased in the United States over the past 30 years, but has leveled off in recent years (7–9). Advances in medical treatments and drugs are contributing to increased survival for persons with some chronic conditions. During this 10-year period, death rates for heart disease, cancer, and stroke declined. In recent years, the percentage of Americans who were aware of their hypertension, and the use of hypertension medications, has increased.

The rising prevalence of MCC has implications for the financing and delivery of health care. Persons with MCC are more likely to be hospitalized, fill more prescriptions and have higher annual prescription drug costs, and have more physician visits. Out-of-pocket spending is higher for persons with multiple chronic conditions and has increased in recent years.

Chronic disease, and combinations of chronic diseases, affects individuals to varying degrees and may impact an individual’s life in different ways. The increasing prevalence of MCC presents a complex challenge to the U.S. health care system, both in terms of quality of life and expenditures for an aging population.
Current and incipient Old Coots (like me), with our accrued Co-morbid Chronics, we're gonna hammer the system, in terms of UTIL.

One thing that will help:

The progress of modern applied science has been defined by a series of outrageously ambitious projects, from the effort to build the first atomic bomb to the race to sequence the human genome.

For scientists and engineers today, perhaps the greatest challenge is the structure and assembly of a unified health database, a "big data" project that would collect in one searchable repository all of the parameters that measure or could conceivably reflect human well-being. This database would be "coherent," meaning that the association between individuals and their data is preserved and maintained. A recent Institute of Medicine (IOM) report described the goal as a "Knowledge Network of Disease," a "unifying framework within which basic biology, clinical research, and patient care could co-evolve."

The information contained in this database - expected to get denser and richer over time -- would encompass every conceivable domain, covering patients (DNA, microbiome, demographics, clinical history, treatments including therapies prescribed and estimated adherence, lab tests including molecular pathology and biomarkers, info from mobile devices, even app use), providers (prescribing patterns, treatment recommendations, referral patterns, influence maps, resource utilization), medical product companies (clinical trial data), payors (claims data), diagnostics companies, electronic medical record companies, academic researchers, citizen scientists, quantified selfers, patient communities - and this just starts to scratch the surface.

The underlying assumption here is that this information, appropriately analyzed, should improve both our potential and attained health, pointing us towards future medical insights while enabling us to immediately improve care by optimizing the use of existing resources and technologies...
Well, yeah. Lawrence and Lincoln Weeds' "Medicine in Denial" 101.

 A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs— is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.
Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $21⁄2 trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.

This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about...
Medical practice is thus trapped in a subjective realm. Unlike scientific practitioners, medical practitioners do not operate in an objective realm, where the contents of thought and knowledge exist independently of the individual mind, a realm where knowledge can be reliably transmitted and applied, where new knowledge can be rapidly translated into practice, where all knowledge can be tested against patient realities. Isolated from this objective realm, the mind becomes a negative force, a cause of confusion and disorder. Physicians are not equipped to fulfill their immense responsibility safely and effectively. Other practitioners are not equipped to share that responsibility with physicians. Patients are not equipped to work effectively with multiple practitioners, nor to assume the ultimate burden of decision making over their own bodies and minds. Third parties are not equipped to create order out of this chaos. Practitioners and patients are not accountable for their own behaviors, while third parties are left free to manipulate disorder for their own advantage.

In short, essential standards of care, information tools and feedback mechanisms are missing from the marketplace. These missing elements are in large part already developed (see parts IV and VI below). Yet, the underlying medical culture does not even recognize their absence. This does not prevent some practitioners from becoming virtuoso performers in narrow specialties or skills. But their virtuosity is personal, not systemic, and limited, not comprehensive. Missing is a total system for enforcing high quality care by all practitioners for all patients...
Medical decision making requires sorting through a vast body of available information to identify the limited information actually needed for each patient. That individually-relevant information must be applied reliably and efficiently, without unnecessary trial and error. This requires highly organized analysis. Educated guesswork is not good enough.

Organized analysis can begin with a simple process of association. In the diagnostic context, this means linking a symptom with associated diagnoses, linking each one of those diagnostic possibilities with readily observable, inexpensive findings associated with each diagnosis, checking all of those findings in the patient, and comparing actual, positive findings on the patient with the array of diagnostic possibilities and associated findings. The output of this process reveals how well each of the diagnostic possibilities matches the patient. (Such a process of association should similarly form the basis for selecting among different treatment possibilities, as we shall see.)

This process of association is simple in two senses. First, the data items are quick, inexpensive, non-invasive findings from the patient history, physical examination and basic laboratory tests. Second, no clinical judgment is required to establish the simple associations between the findings and the diagnoses. The associations (distilled from the medical literature) are mere linkages that computer software can instantly arrange and rearrange as needed.

Physicians are not trained to begin diagnosis using external tools for this simple associative process. Instead, they employ clinical judgment from the very outset of care. Somehow, at each encounter with a new patient, physicians must rapidly select the right data, and then analyze that data correctly in light of vast medical knowledge. They believe that their judgment organizes data collection and analysis in a scientifically sophisticated manner (referred to as “differential diagnosis” in the diagnostic context). This is believed superior to mere information processing, because it applies scientific knowledge and, when successful, minimizes unnecessary data collection. An example is the correspondent (discussed in the preceding section) who analyzed very limited initial data in the case study and “came to just one possibility—Addison’s disease.” Moreover, clinical judgment involves observation and intuition based on personal interaction with the patient, informed by long experience with innumerable other patients. Physicians thus believe that clinical judgment involves much more than educated guesswork.Yet, it is a fantasy to think that clinical judgment enables physicians to analyze patient problems reliably and efficiently.
Were I The Boss of Health Care, this book would be Med School Year One Semester One Required Reading. It's that good.


Check this out. I've written before about the promise of open source apps, including HIT and statistical apps.

OK, so, as I post this we're mostly all fixated on the 2012 Summer Olympics. Here's a little bit of open source data mining/modeling (R Language) I ran across today (I have succumbed to the enticement of Twitter, wherein I found the link to this).

This is all it took, 20 brief lines of code*:
url <- ""
data <- readHTMLTable(readLines(url), which=2, header=TRUE)
golddata <- subset(data, Medal %in% "GOLD")
golddata$Year <- as.numeric(as.character(golddata$Year))
golddata$Result <- as.numeric(as.character(golddata$Result))
logistic <- drm(Result~Year, data=subset(golddata, Year>=1900), fct = L.4())
log.linear <- lm(log(Result)~Year, data=subset(golddata, Year>=1900))
years <- seq(1896,2012, 4)
predictions <- exp(predict(log.linear, newdata=data.frame(Year=years)))
plot(logistic,  xlim=c(1896,2012),
     xlab="Year", main="Olympic 100 metre",
     ylab="Winning time for the 100m men final (s)")
points(golddata$Year, golddata$Result)
lines(years, predictions, col="red")
points(2012, predictions[length(years)], pch=19, col="red")
text(2012, 9.55, round(predictions[length(years)],2))
The R script simply parses out the data from this web page,

fits models from the numbers, and constructs the foregoing graphic.

That's pretty compact. Nice nested command/function calls, etc. Original article here.
* Assumes a (free) R Language runtime interpreter environment install.

Winning time in the 100 metres was 9.63. Usain Bolt of Jamaica.

I was just a bit curious, so I tabulated only the 20 years' of winning times prior to this year's event.

Fitting a basic polynomial (recall that hated old high school algebra?) got me to 9.64 seconds for 2012 , putatively 5x more "accurate" than the R Language model.

Just lucky there. I seriously doubt it'll be anywhere near polynomial-proportionally faster in 2016. In fact, the first-order linear trend (red dash line) might well prove more "predictive" given the visually evident inter-Olympics variance.


Palantir is inspired by a simple idea—that with the right technology and enough data, people can still solve hard problems and change the world for the better. For organizations addressing many of today’s most critical challenges, the necessary information is already out there, waiting to be understood.

Nice. Still researching these people. One linked enterprise I found:

AnalyzeThe.US allows anyone to use Palantir to explore vast amounts of data only recently released into the public domain, including key datasets from Information about key individuals, organizations, and activities exists in many places, and conducting meaningful analysis first requires the ability to integrate data seamlessly and completely. AnalyzeThe.US brings critical knowledge together on a single stage, while providing rich analytical applications that enable anyone to develop an intuitive picture of the complex flow of resources, money, and influence that affect how our government functions. Ultimately, by allowing citizens to analyze our democracy, AnalyzeThe.US democratizes analysis.
I signed up for an account immediately. I've already used, but this looks like it will simplify doing (some) analytics.

I like their avowed commitment to "Civil Liberties / Privacy."
Palantir Technologies is a mission-driven company, and a core component of that mission is protecting our fundamental rights to privacy and civil liberties. Since its inception, Palantir has invested its intellectual and financial capital in engineering technology that can be used to solve the world’s hardest problems while simultaneously protecting individual liberty. Robust privacy and civil liberties protections are essential to building public confidence in the management of data, and thus are an essential part of any information system that uses Palantir software.

A core engineering commitment

Some argue that society must “balance” freedom and safety, and that in order to better protect ourselves from those who would do us harm, we have to give up some of our liberties. We believe that this is a false choice in many areas. Particularly in the world of data analysis, liberty does not have to be sacrificed to enhance security. Palantir is constantly looking for ways to protect privacy and individual liberty through its technology while enabling the powerful analysis necessary to generate the actionable intelligence that our law enforcement and intelligence agencies need to fulfill their missions.

We believe that privacy and civil liberties-protective capabilities should be “baked in” to technology from the start rather than grafted onto it later as an afterthought. By seamlessly integrating these features into our software, we reduce user friction that might otherwise create incentives to try to work around these protections. With the right engineering, the technologies that protect against data misuse and abuse can be the same technologies that enable powerful data analysis.
Yeah, we'll see. Talk is cheap. I've been a bit of Crank on the whole "privacy" thing for a long time (ironic to an extent, given my all-over-the-internet presence).

Can't wait to starting drilling down into this (below, installed on my iMac):


Thomas E Sullivan, MD Chief Privacy Officer, Chief Strategic Officer DrFirst.Com, Inc. testifies before ONC

...We have been talking about “administrative simplification” for many years, even prior to the passage of HIPAA. Although there has been progress, much remains to accomplish.
I believe physicians and selected other clinical providers are among the most highly credentialed and authenticated professionals in our society. There are very many examples of redundancy, unnecessary delays and excess expenses in carrying out these programs. Physicians are typically licensed in one or more states, separately credentialed by many health plans and a few hospitals and also undergo certain privileging criteria within each hospital or otherwise licensed facility. The system is getting more complex daily and cries out for a streamlined and collaborative approach which I believe is part and parcel of the vision maintained by an NSTIC.

Cost effective care and the elimination of redundancy need to be hallmarks of 21st century medicine. Put in another way, although the first rule of medicine traditionally recommended for physicians is:

“Primum Non Nocere”.....First, Do No Harm

I would add Dr. Sullivan’s second rule:

“Secundo, Propera Ne Me”....Second, Don’t Slow Me Down

Indeed. Can you say "workflow"?


Welcome to eCW Talks, a blog initiated by eClinicalWorks to keep you informed and up-to-date on the happenings here, in our extended community and the electronic health records industry in general. We have always committed ourselves to staying ahead of trends and this will be one vehicle for that. Posts will come from me and various additional experts that can provide a new voice and unique glimpse into the topic covered by that entry. In this ever evolving market, it is important to us that we are a trusted resource, acting as transparent as possible.
This should be interesting.

August 4th HIT / workforce update:
Nursing, Engineering Invention Launches; Improves Nurses Worldwide
Cross-posted with permission

A joint endeavor between the colleges of nursing and engineering has been launched as a new product to help build a better workforce of health professionals worldwide.

Called Lippincott’s DocuCare EHR, the new product integrates electronic health records (EHR) commonly used in hospitals and medical offices into a simulated learning tool for students. Proficiency using EHR is paramount for nursing students as the Obama administration has challenged health care providers nationwide to transition to this new technology.

The device was developed by Tami Wyatt, associate professor of nursing, and her graduate student Matt Bell (now an alumnus), along with Xueping Li, an associate professor in industrial and information engineering, and his graduate student, Yo Indranoi. Lippincott Williams & Wilkins (LWW), a leading international publisher for health care professionals and students, purchased the invention in 2010. It is now being marketed worldwide.

“Today’s new graduate nurses must be adept in using this technology, including electronic health records, to comply with accreditation standards,” said Wyatt. “Relying on the limited exposure to EHR technology that nursing students get during their clinical experiences is just not enough.”

By integrating EHR technology into multiple courses across the nursing curricula, the product provides continuity in learning, and students begin relying on EHRs as tools to gather data and anticipate patient care.

The product includes more than seventy pre-populated simulated patient records and cases. Each case includes links to LWW textbooks, giving students access to diagnosis information, procedure descriptions and videos, and other evidence-based content that is used in over 1,200 hospitals nationwide.

Instructors can bring classroom case studies to life by creating simulated patient records, building assignments, and evaluating student documentation performance. The program is designed to better prepare students for practice, in a fully realistic, yet risk-free, simulated environment. LWW will train faculty on how to use this new tool and integrate it into their curriculum.

As part of an ongoing partnership with Laerdal Medical—the top distributor of simulated mannequins for nursing education—the tool includes a variety of Laerdal’s patient scenarios and simulations.

The development of the tool, which began in 2007, has been a collaboration across UT’s campus. Law students offered legal advice for the startup company that marketed Lippincott DocuCare before it was purchased by LWW. Business students helped design a business plan. The UT Research Foundation copyrighted the technology.

Wyatt and Li are co-directors of the Health Information Technology and Simulation Laboratory (HITS Lab), an organized research unit at UT. The overall goal of the HITS Lab is to advance the science of health information technology and examine ways HITS enhances consumer health and professional health education.

To learn more about DocuCare, including purchasing information, visit the website.

Whitney Heins (865-974-5460,

This UTK alum is pretty proud.


Atigeo Launches Big Data Semantic Search Tool Using NIH PubMed

Atigeo, a big data analytics company, has launched PubMed Explorer, an application that allows medical researchers to search the federal database to present results of medical studies based on context in a graphical display.

PubMed is a National Institutes of Health database that provides access to more than 400,000 medical research documents.

PubMed Explorer uses Atigeo's xPatterns big data semantic search platform in the cloud to fine-tune search results so the database can learn the user's search patterns. PubMed's linear search capabilities slow medical research, according to Atigeo.

xPatterns can apply analytics to PubMed's unstructured data set to deliver relevant results by generating domain concepts, Atigeo reported.

Semantic search is a form of technology that can deliver results based on the context of a search term...
Yeah, "semantic search." Seems like that would lend itself to the analytics problems inherent in "semi-structured / narrative" EMR notes. Check out the interesting Atigeo xPatterns YouTube below.



  • Whether you are already a Healthcare IT Consultant, looking to get into the business, or have a need for Healthcare IT resources, gBench simplifies the engagement process by giving consultants and recruiters the information they need to determine where their best time is spent.
  • Consultants can build a robust profile in minutes utilizing our standardized naming convention for skill sets, detailed contract preferences, and the ability to publish your availability.
  • Employers search the network according to their acceptable engagement terms and timelines with the option to send opportunities to qualified consultants.
  • Eliminate the fluff...and get to the point!  Join gBench and get in the game!
Dr. Rowley (Practice Fusion co-founder) sent me a LinkedIn invite to sign up for this. Nice of him. So, I signed up. We'll see what happens. Smells like Teen Spirit to a degree.


$6.174 billion paid out. PDF link to the report here.

More to come...

Wednesday, July 25, 2012

Post MU incubation

My friend Dr. Salber. A new initiative.
Our mission is to help young health tech companies find the resources they need:
  • Money to grow your company
  • Clinical, population, and patient feedback on your ideas
  • Advice from experts
Health Tech Hatch is an online and mobile resource for health technology entrepreneurs providing crowdfunding, clinical and usability feedback, and community for young companies developing digital solutions for the health care and wellness industries. Health Tech Hatch also serves as a resource for entrepreneurs seeking relevant populations on which to pilot-test their applications at scale, and provides other consulting services to new health technology companies.
Let a thousand flowers bloom, indeed.

Apropos of the topic. Just released:

Patient-­‐Centered Outcomes Research (pdf)

As each of us travels the path of healthy to sick, person to patient, we are faced with a series of choices. Should we have an operation or stick with the pills for our heartburn? Should we take that screening test or skip it and hope this is not the year that we develop cancer? Is it time to bring my feverish child to the doctor or can I wait another day? Each of these decisions, and all the other decisions we make over the course of a lifetime, accounts for much of our personal experience with the healthcare system. The remainder of that experience relates to living with the consequences of the decisions and choices we make. Some of us do our own research at the library or on the internet, while others count on the advice of someone they trust. No matter how we make these decisions, we all agree on one thing: we want to rely on the best possible information.

The information we need to make decisions most often comes from clinical research. Clinical research includes investigations undertaken by scientists, who decide which questions to ask, what approaches to take, how to perform the work, how to interpret the results, and then ultimately how to disseminate the findings through scientific journals or other means. The last 75 years of clinical research has been marked by phenomenal advances in knowledge about the causes of disease and their treatments. Our nation’s public and private research funding organizations have helped transform modern medicine, influence the daily healthcare of all of us, and have contributed to unprecedented health and well being of our country.

Yet while these successes are all around us, from the perspective of many patients facing health decisions, this research process often misses the mark. Sometimes the research is performed on people who are so different from us that we can’t interpret the results. It includes subjects of different ages, sex, race, and without the complexity of conditions that we have. It sometimes involves treatment in care settings not enough like ours—-sophisticated research centers rather than places more like the communities in which we live. It sometimes focuses on choices that don’t apply enough to us—expensive treatments that we have to drive hundreds of miles to receive or that we might need to pay for out of pocket ... if we have the money or time. It sometimes deals in outcomes we don’t always think are that important—whether or not our blood tests are getting better instead of whether we feel better. For a lot of us, this gap between the information we need and the information we get from research leaves us without the kind of useful information we need to make healthcare decisions. We are often left frustrated by the information we have...
PCORI is one of the many initiatives that survive, given the SCOTUS decision upholding the PPACA.
The Patient Protection and Affordable Care Act (PPACA) of 2010 created the Patient-Centered Outcomes Research Institute (PCORI) to support research that can produce the type of information people and their caregivers need when they face a healthcare decision (Appendix E). The purpose of PCORI is to provide the most reliable, relevant, and useful health-related evidence for decision- makers, especially for patients and caregivers. In 2012, the Methodology Committee and the PCORI Board approved a working definition that reflects this perspective...
May the effort bear orchards of fruit.

From my friends at Ober Kaler:


Health Law Alert Newsletter
2012: Issue 12 - Focus on HIPAA/Privacy
By: James B. Wieland and Joshua J. Freemire

A number of health care providers that attested to Meaningful Use for Stage 1 have received a letter from an Figloiozzi and Company, acting as CMS's auditor for the EHR Incentive Program (the "Program" or "Meaningful Use Program"), requesting certain records related to the attestation. CMS has not, as of this writing, made any announcement of this audit initiative or of the engagement of Figloiozzi and Company. While it is always good policy to confirm the identity and authority of any entity claiming a right to review or audit records, these letters are legitimate. Citing its statutory authority under the American Recovery and Reinvestment Act (ARRA), and without any fanfare, CMS has begun to audit the attestation materials.

The letters from Figloiozzi and Company, as the Department of Health and Human Services (HHS) Secretary's designee, request four categories of information:
  • Audited entities are asked to produce a copy of their certification from the HHS Office of the National Coordinator for Health Information Technology for the technology they used to meet Program requirements. Presumably, this documentation will be used to demonstrate that the entity "possesses" a certified Electric Health Record technology system as required under Program rules.
  • Audited entities are asked to provide documentation to support the method (observation services or all emergency department visits) they chose to report emergency department admissions. This distinction plays a large role in several of the Program requirements as it determines which patients were included in the denominators of certain meaningful use core and menu items.
  • Audited entities are asked to supply supporting documentation with regard to their completion of the attestation module responses as to core set objectives and measures. While the audit letter's request is not specific, it would appear that this request is intended to solicit information beyond that already provided to CMS as part of the attestation process. A hospital might consider, for instance, producing reports substantiating the encounters that gave rise to the calculation relied upon to successfully attest. Such reports should be deidentified.
  • Audited entities are asked to supply supporting documentation with regard to their completion of the attestation module responses as to "menu set" or voluntary, objectives and measures. Again, the information request appears to solicit a level of information beyond that provided in the attestation documents themselves...


The first National Physicians Survey was conducted in 2011 to primarily evaluate physician attitudes about the emotionally charged Health Care Reform Act of 2010 (PPACA), and how it would affect their practice, income, and patients. Although this act has been the topic of heated political debates and extensive press coverage, less attention had been paid to what doctors themselves thought of the new law. The results of last year’s survey were distributed on Capitol Hill and featured in numerous publications.

Since the 2011 survey, the issues surrounding healthcare have continued to evolve, as have the impact of other external factors on practitioners.

The objectives for the 2012 National Physicians Survey build on last year’s approach, with 10 questions inquiring about change, and investigating how that change has impacted daily activities...

Where possible, we share varied opinions among respondents to identify contrasts among the physician base as a whole. For the broader topics, we share the changes in opinion from last year’s survey to this year’s.

The National Physicians Survey is unique, providing insight by listening to the practicing clinician during this time of change in healthcare. The physician voice is the equivalent of the “man on the street” when it comes to healthcare – the bridge between the regulations, laws, and administration and the health of an individual patient.

We look forward to always continuing this dialogue with practitioners about tools and resources that physicians are using to make their practices more efficient, where they think their practice will be in the future, and who will be the partners that get them there.

Nicely done. One of the unhappy stats: nearly 3/4 of the respondents (71%) believe that the quality of care in the U.S. will decline across the next 5 years.

Love this, too: "Fax remains king, but email is sneaking into the mix...regardless of what HIPAA says."
As expected, telephone and fax led the physician-to-physician interactions. Faxing was selected by over 60%. While the fax may be all but absent from many other business environments, replaced by email, this channel securely supports hand-written notes, insurance forms and lab test results. Consider this “dinosaur” of a channel as we look at physician responses; for good reason, many physicians are treading cautiously into the digital space.

Free PDF download. A joint production of The Little Blue Book and Sharecare.



So, the draft "consent management process" debate continues at my HIE. "Opt in," opt out," who's gonna be on the hook for obtaining it and riding herd on it, yada yada yada. One of our consultants got all agitated last week during a conference call over the prospect of permitting patients to rescind HIE consent at will. Notwithstanding that everyone assumes that we have to obtain it at the outset, this consultant, seeing a potential quagmire of endless consent revisions, argued that "once you're in, you're in, period."


Well, beyond that, it turns out that "consent" for "treatment, payment, or health care operations" appears to be optional under HIPAA (though stricter state laws would override that). From HHS:
What is the difference between “consent” and “authorization” under the HIPAA Privacy Rule?

The Privacy Rule permits, but does not require, [emphasis mine] a covered entity voluntarily to obtain patient consent for uses and disclosures of protected health information for treatment, payment, and health care operations. Covered entities that do so have complete discretion to design a process that best suits their needs.
By contrast, an “authorization” is required by the Privacy Rule for uses and disclosures of protected health information not otherwise allowed by the Rule. Where the Privacy Rule requires patient authorization, voluntary consent is not sufficient to permit a use or disclosure of protected health information unless it also satisfies the requirements of a valid authorization. An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.

An authorization must specify a number of elements, including a description of the protected health information to be used and disclosed, the person authorized to make the use or disclosure, the person to whom the covered entity may make the disclosure, an expiration date, and, in some cases, the purpose for which the information may be used or disclosed. With limited exceptions, covered entities may not condition treatment or coverage on the individual providing an authorization.
Now, the salient distinction they offer up is this:
An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.
 OK. 45 CFR 164.501 (pdf)
Health care operations means any of the following activities of the covered entity to the extent that the activities are related to covered functions:

(1) Conducting quality assessment and improvement activities, including outcomes evaluation and development of clinical guidelines, provided that the obtaining of generalizable knowledge is not the primary purpose of any studies resulting from such activities; population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting of health care providers and patients with information about treatment alternatives; and related functions that do not include treatment;

(2) Reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance, conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers, training of non-health care professionals, accreditation, certification, licensing, or credentialing activities;

(3) Underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care (including stop-loss insurance and excess of loss insurance), provided that the requirements of §164.514(g) are met, if applicable;

(4) Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs;

(5) Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or coverage policies; and

(6) Business management and general administrative activities of the entity, including, but not limited to:

(i) Management activities relating to implementation of and compliance with the requirements of this subchapter;

(ii) Customer service, including the provision of data analyses for policy holders, plan sponsors, or other customers, provided that protected health information is not disclosed to such policy holder, plan sponsor, or customer.

(iii) Resolution of internal grievances;

(iv) The sale, transfer, merger, or consolidation of all or part of the covered entity with another covered entity, or an entity that following such activity will become a covered entity and due diligence related to such activity; and

(v) Consistent with the applicable requirements of §164.514, creating de-identified health information or a limited data set, and fundraising for the benefit of the covered entity.
 Not a whole lot left, in practical terms. You could drive a fleet of trucks through that opening. Though, in fairness, there are issues such as "Marketing," (pdf) "psychotherapy notes," "substance abuse," and the like.

So, "consent" is largely optional, "authorization" is required in some circumstances, and is revocable at will (whereas "consent," once given, is not as a matter of federal law and regulation).

And, all of which defer to more stringent state laws.

Got it?



Gotta say, I love the convenience of e-books, though, it's too easy to make impulse download purchases and buy more than you can keep up with.

Shot that with my iPhone.

Speaking of the iPhone: July 26, 2012 update

So, one of my coworkers today told me that there's a free Dragon app for the iPhone. Well. there indeed is. How did I miss that? Here I am dictating my blog post update into my iPhone, which I'm then going to send via e-mail and then screen scrape it off and copy and put it right into the blog. Pretty neat. I didn't realize that. Cool.

Sent from my iPhone

[P]rofessionals who had signed an agreement to receive technical assistance from a Regional Extension Center were more than twice as likely to have been awarded an incentive payment (pg 6).

Elsewhere, in an otherwise negative-spin article posted on EHR Intelligence:
RECs are a game-changer: Those professionals working with Regional Extension Centers (RECs) (18.7%, 12,155) were more than two times more likely than those who didn’t 44,430 (8.3%, 44,430).
MORE iPhone: a $1.99 ECG App

From The Health Care Blog:
How the iPhone Might Disrupt The Medical Device Industry
 Doctors wanting to determine a patient’s atrial fibrillation burden have a myriad of technologies at their disposal: 24-hour Holter monitors, 30-day event monitors that are triggered by an abnormal heart rhythm or by the patient themselves, a 7-14 day patch monitor that records every heart beat and is later processed offline to quanitate the arrhythmia, or perhaps an surgically-implanted event recorder that automatically stores extremes of heart rate or the surface ECG when symptoms are felt by the patient. The cost of these devices ranges from the hundreds to thousands of dollars to use.
Today in my clinic, a patient brought me her atrial fibrillation burden history on her iPhone and it cost her less than a $10 co-pay.  For $1.99 US, she downloaded the iPhone app Cardiograph to her iPhone.
Every time she feels a symptom, she places her index finder over the camera on the phone, waits a bit, and records a make-believe rhythm strip representing each heart rhythm. With it, comes the date and time...
Interesting. Read on.


Dr. Blumenthal was ONC head from 2009 through 2011.
"We are extremely fortunate to have Dr. Blumenthal take the helm of the Fund at a crucial time in the drive to achieve a high performance health system," said Commonwealth Fund board chairman James R. Tallon, Jr. "If the U.S. is to realize the triple aims of better health, better care, and lower cost, it will need over the next 10 years unstinting efforts by health policy and practice leaders like Dr. Blumenthal. He is ideally suited to carry forward The Commonwealth Fund’s significant role in advancing delivery and payment system changes that will improve system performance."

I finally succumbed, went over to The Dark Side: Twitter.

OK. And, your strategy for making this happen is precisely ______________?

Relatedly, what are the latest developments over at ARCH-IT?

More to come...

Wednesday, July 18, 2012

"The Health Care Handbook" considered

So, yesterday, I ran across this post on The Health Care Blog, wherein the (anonymous) "reviewer" waxed effusive.
The book is the work of two medical students, Elisabeth Askin and Nathan Moore. When Elisabeth and Nathan worked to educate themselves about the American health care system they couldn’t find a source that was comprehensive, understandable and non-biased – so they decided to write it themselves. After thousands of hours of research, writing, and consulting with dozens of national experts, the Health Care Handbook is now available. It’s rigorously researched and scrupulously unbiased yet written in a conversational and humorous tone that’s a pleasure to read and illuminates the convoluted health care system and its many components. The book is essential reading for health professionals, health professions students, and anyone who interacts with the U.S. health care system.
$7.99 Kindle edition? Safe bet. 1-click Whispernet, whoosh...

I downloaded and read it. Nicely done. If you've been immersed in the health care system for as long as I have, you won't find much new detailed information here, but, as the authors note, that's not the principal audience.
We’re students ourselves, so we have firsthand insight about what students don’t know, what they want to know, and what they need to know. As such, students are our primary focus for this book...
We think the book will hold the most value for the following:
  1. Students in undergraduate, graduate, and professional programs focused on medicine, nursing, dentistry, pharmacy, allied health, medical research, biotechnology, public health, public policy, economics, finance, health care administration, business, and law. Heck, throw in history and political science, too! 
  2. Health care professionals who want to expand their knowledge about what affects them in the workplace or who want a reference for continuing education. 
  3. Lay readers who are sufficiently interested in learning more about health care to have started reading a book about it. In short, if you ever find yourself confused by a news article about what an Accountable Care Organization is, or you don’t have quite enough information to argue with your Uncle Dan about pharmaceutical companies, or you’re annoyed that everything you read has an agenda— then this book is for you.
    (Kindle Locations 179-180)
I find it indeed balanced and comprehensive -- at a (probably appropriate) "survey course" level. It has been worth my money and my time. See also the NY Times' recent "Two Medical Students Navigate the Health Care Maze."

My only laments go the the short shrift given HIT (in addition to an equally cursory treatment of clinical "statistics"):
Health Information Technology 

While the technology used in medical devices continues to improve, health care communication and organization systems at most institutions are stuck in the pagers-and-faxes era. (Unfortunately, they've ditched the acid-washed jeans.) Health information technology (IT) is a simple concept: the application of electronic systems in organizing and using health data, from writing prescriptions to transmitting MRI results digitally. However, as with many aspects of health care, this simple concept quickly becomes extremely complicated when put into practice. For one, health IT goes by many different names, such as electronic health records (EHR), electronic medical records (EMR), and personal health records (PHR). Different software systems may all call themselves EHR, which would suggest they are comparable; however, they may not perform the same functions or have the ability to communicate with each other. The best definition and system may not be clear for those who are actually using it to provide care.
What is clear is that health IT has the potential to significantly improve the efficiency and error rate of health care systems. (Spell check is pretty great and all, but ending the tyranny of physicians’ messy handwriting is a true feat: now 25% of prescriptions are issued electronically.)   Of course, potential doesn’t necessarily equal results— the largest study to date failed to show any improvement in quality of care, cost, length of stay, or readmission rates for hospitals that have implemented EHRs. Health IT penetration is still relatively low in the U.S. — only 1.5% of hospitals have comprehensive EHR systems, while 7.6% operate a basic EHR. Nevertheless, the federal government has prioritized health IT and has unveiled a range of measures to encourage the adoption of EHRs across the country. Interestingly, the one area in which health IT has already been implemented quickly and universally is medical billing— 99% of hospitals have computerized patient billing systems. Money has an uncanny ability to speed anything along, doesn’t it? (Kindle Locations 2256-2271)
That's pretty much it. Also, search on "health information exchange," "HIE," "interoperability," "meaningful use".

Nada. Zilch. "0 matches found."

Well, another resource that fills in some of the blanks. Recall my March 28th, 2012 post, wherein I reviewed Fred Trotter's excellent "Meaningful Use and Beyond."

This book rocks!

As do Joe Flower's "Healthcare Beyond Reform," and Dr. Toussaint's "Potent Medicine" and "On The Mend" (scroll down in the latter two posts), to cite just a few of my top 10.

As does the compelling "Medicine in Denial," which I've cited multiple times.


Why the EHR market is on the brink of mass consolidation
July 18, 2012 | Robert Rowley, MD, Healthcare and health IT consultant, practicing family physician

The number of vendors of Electronic Health Records products seems unsustainable. Stimulated by federal Meaningful Use incentives, plus the irresistible tide of pressures and encouragement from all sides (specialty societies, peers, licensing boards, insurance payers), the uptake of EHRs has been steadily increasing...

This scenario seems ripe for consolidation. Market forces, however, are rather Darwinian – novel approaches abound (“mutation”), but many will not achieve market penetration (“selection”). Failure of products, even well-designed ones, are part of the startup experience – true in all market spaces, not just health care.

There will likely be some consolidation. As is seen in other sectors, when companies buy other companies it is more a purchase of their market footprint than it is a purchase of their technology. In fact, examples of mergers with ultimately incompatible technologies behind them abound...
So, nearly half of the "certified" EHRs have no attestors to date? I'm havin' a Clinic Monkey Moment.

Yes, there will indeed be a "shakeout."

More Dr. Rowley:

Market analysis of the EHR industry is compiled from 2011 Meaningful Use data. This 116-page comprehensive document is intended to be an indispensable resource for those who want a detailed understanding of the current state of the EHR industry – consultants, vendors, and investors will find this an important reference manual as they view the competitive landscape of Electronic Health Records (both ambulatory and hospital).
$6.90 a page. Can you say "nano-niche market"?


As of today 141 relational tables (these people are busy). I'm working on tallying up all of the vars and their cumulative data storage and bandwidth overhead. This (above) is a snip from the audit log dictionary.


Nice presentation deck here (PDF).


This is nicely done. You can click state by state (and by other criteria) for interactive statistical graphics.

Click to enlarge. Note that, as of "04/31/2012," (red oval annotations) our Utah brethren were kicking our Nevada butts. But, they have one major vertically integrated system (IHC) and one major metro area to service as a priority. We have to deal with Clark (S) and Washoe (N) counties (far flung, comprising ~90% of the state population), and have a number of competing delivery systems along with our (ever-declining) independents.

More to come...

Monday, July 9, 2012

Analytics - SAS, R, SQL, EHR database schema. An old school data miner's ramble involving the intersections of workflow, audit logging, and CER, etc.

Above, a tiny close-up snip from the original "RDBMS schema" (pdf) of "OpenEMR," an open-source ONC MU certified complete-system ambulatory EHR. When health care IT and clinical people give you that "yeah. but, we're different" beg-off, it's by no means baseless.

The full schema depicts a data dictionary layout of 54 linked tables and about 20 more reference tables. I haven't yet tallied up the total number of variables. Many hundreds, minimally.

Much more to come on all of this. I've been too busy playin' this weekend. A musical reflection on the SCOTUS ruling on the PPACA. (There's a tangential connection here, which I will get to.)


Open EMR pretty much rocks! Browser agnostic, too. It's PHP scripting language embedded in browser html code, pulling in Javascript and CSS (Cascading Style Sheets) as well. End user data are saved to, retrieved from SQL tables.

The data dictionary now comprises 118 relational tables.

Because it's open source, you can modify/extend everything and anything. Below, selected data table edit "masks" (you can modify/extend those as well).

I would change some of those "open text" data items to "forced choice format."
I crashed around in the demo for a while, and then dumped an audit log. Exported (.xls) snippet below.

Chronological user sort excerpt, from the time I logged in (that's our HealthInsight Las Vegas IP address at the top). Eleven "events" across 01:43 (avg 10 seconds per). Quick bit of Excel "lag variable" function code off that data/time variable, and I have essentially an EHR information "workflow" record (which I could then illustrate in one way or another). The "comment" column / "field" is the one with the variable length PHI "action(s) taken" piece (per §170.210.b). It will require some study (for granularity, among other things) and extractive analytic coding.


I just signed up for this. I've been a CS3 user for some time now, so I qualified for the $29.95 a month plan. ~A buck a day (for year one: there's always a catch, but, I'll cross that bridge when I come to it). Simply upgrading to the core CS6 Suite from my CS3 old release would have been about $600. There are 17 total apps in this "cloud" suite, I'm installing them this evening (You get to install the various component executables locally. I assume you then have to be logged in to run them. We shall See. No biggie).

Ought to be interesting.


Hmmm... for the other side of HIT data, 'eh? Touted as providing SAS / SPSS / Stata level stats computing power.

I may have to dust off my old software coder hat. Open source as well. (No way can I afford a SAS seat, not even JMP).

"R" is an is an offshoot of the Bell Labs "S programming language." I used "S Plus" while working in credit risk management (mainly FOR "CART" analytics, a.k.a., "Binary Recursive Partitioning" -- a cool, non-parametric (gotta love it) way of parsing the "goods" from the "bads" in terms of lending outcomes for subsequent scorecard modeling.

Here's what I'm seeing, conceptually.

(a 15 minute Keynote slide export)
I am all over this. So much new stuff to learn and apply.


My latest weekend recreational reading just arrived via UPS.

We shall see. All looks very interesting. As touted on one blog:
Data Mining with R - The Rattle Package

R ( is one of the most exciting free data mining software projects of these last years. Its popularity is absolutely justified (see Kdnuggets Polls - Data Mining/ Analytic Tools Used - 2011). Among the reasons which explain this success, we distinguish two very interesting characteristics: (1) we can extend almost indefinitely the features of the tool with the packages; (2) we have a programming language which allows to perform easily sequences of complex operations...
A couple of Rattle interface shots below:

Apropos of health data analytics, courtesy of Lion Data Systems:

All very encouraging. Time to Get My Geek On.



FDA Spied On Scientist Emails
By Amir Khan | July 15, 2012 9:58 PM EDT
The U.S. Food and Drug Administration operated a so-called "enemy list" of disgruntled scientists and spied of their emails using keylogging software, according to a report by the New York Times.  The operation began as an investigation into the possibility of leaked confidential emails, but grew into a surveillance program into critics of the FDA.

The agency used software intended employers to monitor workers to capture screen images, keystrokes, emails and documents line by line on the scientist's government laptops. The FDA admitted to the New York Times to monitoring five scientists, but said it was only to ensure that no information was improperly used.

The FDA did not immediately return a request for comment.

The product used, sold by the company SpectorSoft, cost as little as $99.95 for individual use, according to the Times. On the website, the company advertises that employers can follow all of their employee's moves online.

"Monitor everything they do," the website says. "Catch them red-handed by receiving instant alerts when keywords or phrases are typed or are contained in an e-mail, chat, instant message or Web site."...
Hey: Keywords "EHR usability and safety oversight," lol...

OK apropos of my diversionary GarageBand fun last week, in the context of "workflow."

OK, nominally "obtuse" though I may seem, I will elaborate shortly and tie off the foregoing threads of thought.

Hint: "time-based information workflows" - they're right there for the culling and investigation for process improvement, right within the EHR audit logs.

More to come...