Dog Days errata

Not a lot going on this week. Nevada Medicaid's attestation portal launched without major snags. I have a few Medicare EPs trickling in to Milestone 3. My wife is in Dubai this week making grown engineers and construction crew chiefs cry. We're 11 hours apart. Makes it difficult to stay in touch.

I joined the International Association of Privacy Professionals. Looks pretty interesting thus far. If you work for a non-profit, you get a 60% discount (100 bucks rather than $250).

I may study up and take their "CIPP/US" Cert exam. The BoK all looks pretty familiar, given a good bit of the work I now do.

apropos of "privacy": Fine new book out, Garrett Keizer's "Privacy."

I've read this guy before, in Harper's. Excellent writer.

It is a curious paradox of the times we live in, when no commandment is inscribed on tablets of stone but every one of our transgressions lives eternally within some data bank, effectively beyond the pale of forgiveness...

...corporations mine our e-mails and Internet searches in the hopes of honing their marketing strategies. No sooner do I press the send button that e-mails a letter of recommendation to a female student or a note of thanks to a female editor and an ad for an online dating service invites me to learn more about a bevy of eligible lovelies “in your area.” More than 96 percent of Google’s $ 29 billion in revenue for 2010, a sum exceeding the combined advertising revenues of all newspapers, came from advertisers sold on the search engine’s ability to know our individual wants. Unlike Orwell’s Big Brother, who merely sought to sniff out dissent, corporate Big Brother wishes to know our every desire, confident that we can be pleasured into submission. And we have hardly seen the worst. Privacy expert Jeffrey Rosen speculates that “it would be a simple enough task for Facebook or Google” to launch an “Open Planet” surveillance system, by “which anyone in the world could log onto the Internet, select a particular street view  … and zoom in on a particular individual.… Most of the architecture for implementing it already exists.” 

Such a development would be good news not only for the Big Brothers of government and business but also for what Walter Kirn, writing about the Clementi case, calls “Little Brother.” He means any nosy individual with an electronic device. With the use of something called a keylogger, for instance, you can keep track of a spouse’s computer keystrokes. With the use of Google Images you can change your mind about a blind date. The surveillance state and the surveillance economy are matched by a surveillance culture, each daring the other to go one step further in vandalizing old norms...

...My hunch will hold water for anyone who has attended a loved one in a medical emergency or worked as an advocate for the aged, the poor, or the otherwise disadvantaged. Advocates in particular will understand the hostage mentality of marginalized patients dependent for their deliverance on an all-powerful professional. Asking such people if they’d have any objection to some optional waiver of their privacy rights is like having your daughter’s kidnapper ask if you’d mind him using your restroom before he tells you the terms of her ransom. Whatever you do, don’t make him mad at us!

Keizer, Garret (2012-08-07). Privacy (Big Ideas//Small Books) (p. 6, 7, 71). Macmillan. Kindle Edition.

Highly recommended.
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Regarding HIE, this is pretty cool:

Ryba's 16 rules of effective HIE
August 10, 2012 | Joel Ryba, COO, HIXNY

1. Assured Delivery Rule. Effective HIE must be able to reliably message between source and destination and confirm delivery. This applies to both data provider into a shared view for query, as well as to data sent to another provider for one-to-one. Exceptions must alert an operator and store the message(s) for reprocessing.
2. Abstraction Rule. Effective HIE must abstract between data provider and data consumer. To do so an HIE must support multiple versions of standard interfaces like IHE and HL7 as well as optionally support non-standard interfaces.
3. Patient Data Locator Rule. Effective HIE must provide the ability to locate patient records – and that means being able to index patient records by linking and unlinking facility/patient records (MRNs or other local IDs) through both statistical matching and manual intervention.
4. Data Integrity Rule. Effective HIE must provide the ability to manage patient data by data source, and not combine the data linked by the Patient Data Locator Rule in any way that cannot be undone if the patient records are unlinked.
5. Query Rule. Effective HIE must provide the ability to Query/Pull from other provider(s) as a single record (individual provider stable record or consolidated on-demand document).
6. On-Demand Consolidation Rule. Effective HIE must provide the ability to Pull a consolidated record on-demand. Ability to consolidate patient data from multiple sources into a single view.
7. On-Demand Aggregation Rule. Effective HIE must provide the ability to aggregate data (counts, sums, averages) for single patients or across multiple patients meeting a selection criteria.
8. Provider Directory Rule. Effective HIE must provide the ability to locate a provider (legal entity like hospital or group practice or an individual clinician) for push messaging and if necessary transform their local facility identifier into a generic address or identifier or into another facility’s local identifier.
9. Direct Push Rule. Effective HIE must provide the ability push a single record and selectively send data to comply with HIPAA minimum necessary requirement.
10. Access Control Rule. Effective HIE must provide the ability to control access based on patient consent and data recipient roles.
11. Subscription Rule. Effective HIE must provide the ability to ‘Subscribe for PUSH’ based on the subscribers rights to the patient data.
12. Audit Rule. Effective HIE must Log all transactions to an audit log. This is necessary for both direct push and query pull. It should also be able to easily be determined what data was accessed. So for instance, if a patient is linked or unlinked by the master patient index before or after the transaction, or some data is or is not included from federated portions of the HIE, the audit must effectively have this level of information (the event patient) captured.
13. Audit Reporting Rule. Effective HIE must provide the ability to Report against Audit data. As with all interfaces, the interface for audit to record information may not be the best way to store the data for query/reporting. Thus, it is likely necessary, but not required by the rule, that there be some level of abstraction between how data is moved and how it is stored.
14. Clinical Reporting Rule. Effective HIE must provide the ability to report clinical data across patients for population health use cases as well as be able to locate patients meeting a clinical profile across all data sources when all data on the patient may come from multiple sources and may be stored in an equivalent federated manner. Thus, it is likely necessary, but not required by the rule, that the federation between data sources need to be treated as nodes or shards of parallel data warehouse for this type of query/reporting versus single patient data accesses.
15. Interoperability Rule. Effective HIE must provide the ability for providers to seamlessly initiate and terminate exchange from their native environment.
16. Customizable Business Rules Rule. Effective HIE must provide the ability for processes to be monitored for compliance to business rules to report or alert for exceptions. For example, care managers with consent from the patient need to monitor their adherence to treatment plans, quality measures, and so forth. This can extend either the subscription rule or the clinical reporting rule depending on how it is implemented.

Tall order. All of these are on our plate these days.

THE "FIGLIOZZI LETTER"

 CMS starts auditing recipients of meaningful use bonuses
Some practices that have obtained incentive payments are being asked to supply documentation supporting their eligibility.
By PAMELA LEWIS DOLAN, amednews staff. Posted Aug. 13, 2012.

...The company contracted by CMS to conduct post-payment auditing of hospitals and eligible professionals who successfully claimed meaningful use has started its work. The auditing process, a congressional requirement under the 2009 federal stimulus package that authorized the EHR bonuses, will be carried out by Figliozzi and Co., an accounting firm based in Garden City...

The letters ask physicians to provide three things, said [Jim] Wieland, who is head of the [Ober Kaler law]  firm’s health care information privacy, security and technology group.

• Proof that the EHR system used to meet meaningful use requirements is certified. The Office of the National Coordinator for Health Information Technology maintains a list of certified systems on its website.
• Supporting documentation proving that core objectives were met. Fifteen core objectives must be met to achieve meaningful use during stage 1 of the initiative. EHR systems certified to meet meaningful use should generate reports showing that these objectives have been met. Electronic or paper copies of those reports should satisfy the request.
• Supporting documentation that so-called menu objectives were met. Those attesting to meaningful use in stage 1 choose five menu objectives from a list of 10. EHR-generated reports, including those used to support clinical quality measures, can show that those objectives have been met.

You get a Figliozzi Letter, you will have two weeks to submit your documentation.

REC LOBBY UPDATE

 

Must not be hasty, one supposes.
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Much more to come. In addition to watching the Olympics, I've been doing a bit of blogging on another topic.

AUGUST 15TH UPDATE

Nice. Got picked up in the MedPedia:

BLUE BUTTON

ONC Aims To Automate Patient Use of 'Blue Button' Application

The Office of the National Coordinator for Health IT wants to make it easier for all U.S. residents to use a "Blue Button" feature to download their electronic health record data, Government Health IT reports (Mosquera, Government Health IT, 8/10)...

I just got a USB flash drive dump of six years' worth of my medical data from my Primary. Blue Button functionality, adroitly ("securely") deployed would have saved me 45 minutes and two bucks worth of gas.
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More to come...

M&M's...?

Wow. Dr. Levy, throw it down!

As well intentioned and thoughtful as he is, Sanjay Gupta nonetheless misses the point in his recent New York Times op-ed “More treatment, more mistakes.”

“One place where I have seen these issues addressed is in Morbidity and Mortality, or M and M — a weekly gathering of doctors, off limits to the public, which serves in most hospitals as a forum for the discussion of mistakes, complications, deaths and unusual cases. It is a sort of quality-assurance conference where doctors hold one another accountable and learn from one another’s mistakes. They are some of the most candid and indelible meetings I have ever attended.”

“Having a consistent gathering to talk about the mistakes goes a long way toward that goal, and just about any institution, public or private, could benefit from a tradition like M and M.”

OMG. Dr. Gupta has inadvertently given us a wonderful exposition about a lack of understanding of the nature of quality and safety process improvement in hospitals. Most harm is not caused by a doctor making an error of commission, i.e., an extra test or an unnecessarily executed procedure. The number of reported adverse events from such instances is dwarfed by other forms of harm — hospital acquired infections, falls, failure to rescue, pre-39 week induced labor. Many of these are not even reportable as harm.

Dr. Gupta’s presentation reflects no knowledge about the science of process improvement. Peter Pronovost’s check list is not just a good idea. Brent James’ introduction of clinical protocols is not just a good idea. These are approaches that introduce the use of the scientific method into the clinical setting. In contrast, M&M conferences are essentially anecdotal reviews of an incredibly small number of adverse events. I would not understate their importance as teaching tools (when they are conducted in a pedagogically appropriate manner), but they do not deal with systemic problems, with near misses, with the manner in which communication fails.

As Lucien Leape [sic] and others have stated, and as Dr. Gupta makes clear in a way he certainly did not intend, the medical profession needs to have dramatically improved training in the science of process improvement as part of the undergraduate and graduate medical education curricula.

Props to The Health Care Blog, which I follow religiously.

"[T]he medical profession needs to have dramatically improved training in the science of process improvement."

Yeah.

I've been advocating such attention since Day One of this blog effort.

Again, Dr. Toussaint:

Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes.To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.

In fact, hospitals, physicians, and nurses—all of healthcare—must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence-based delivery, work that has barely begun.

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There is, however, a good bit of literature on the M&M, in fairness. e.g.,:

PDF here.

Conclusion
The structured hospital-wide MM&I conference is an effective way to engage multiple members of the health care team in a discussion of adverse outcomes, while collaboratively focusing on potential systems-based improvements in patient care and safety. Nonjudgmental case discussion helps overcome the individual’s fear of accusation and criticism, which can stifle honest exchange of information and hinder improvement initiatives. Identification of potential system failures by participants, empowerment of workgroups to address specific systems-based problems, and transparent accountability for regular followup can lead to improved patient safety.

 "Nonjudgmental case discussion." Yeah, great ideal. But, ever heard the phrase "Shame and blame"? Another link as well (there are many).
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INTERESTING WEEK COMING UP
(Aug 5th, 8:30 pm update)

My state has finally gotten off its inertial duff and launched its Medicaid EP Meaningful Use Attestation Portal. Better Late (by a year) than Last In The Nation (we were close, though). The fun begins at 8 a.m. Be an interesting couple of days (and week and month). I expect to be on the phone most of the next couple of days doing repetitive hand-holding.

FAQs here (pdf).
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MEANINGFUL USE CRITIQUE

From EHRintelligence.com

Part II of our conversation with McIntyre brought forward some of the challenges his practice faced during meaningful use attestation. He also discussed where he thinks the Centers for Medicare and Medicaid can improve upon the relationship between government and physicians...

In an ideal world, how should CMS handle meaningful use?
I understand they’re trying to standardize the data collection but they should’ve brought a lot more clinicians into the fold in designing this. They had a comment period and relaxed the meaningful use criteria a bit, but I don’t think they really listened. I think they should’ve made Stage 1 a whole lot easier to comply with just to get people involved. Then you can make it more onerous as it goes forward. You already have people on board and you can work the bugs out that way instead of saying ‘Here’s this onerous criteria and you have to do it or you don’t make the money back and oh, by the way if you don’t do it by 2015 we’re going to start to ding you.’

They should’ve brought more doctors into the conversation and sought out expertise from all specialties. With the quality metrics, they should’ve had a broader base of CMQs. I think it’s great that we’re going to follow outcomes, but let’s follow outcomes then. I mostly have a shoulder practice and there’s not one question. There should be outcomes metrics, we have validated outcome metrics – the America Shoulder Elbow score, several other validated scores you could stick into a metrics process that would be great for collecting data. And we need that data, but there’s none of that in there. It’s a top-down, one-size fits all operation. That means it’s going to be hard to implement and it’s not going to be germane to the practice types. The whole idea about collecting data is collecting good data, right?

How do other physicians that you know feel about meaningful use?
I go to a lot of meetings with other orthopedists and there are a lot of hands raised when asked if they’re applying for meaningful use. It’s not like people aren’t doing it.

Doctors are scared to death of this. They’re looking at the cost, number one. Then they’re looking at implementation of it, number two. Then they’re looking at meaningful use criteria number three. All are separate issues. A lot of them are just saying ‘Uncle’. That’s a big reason why so many [practices] are becoming hospital employees. If they paid us more to do this, if we were somehow incentivized, you could justify it but your reimbursements are going down, costs are going up and now you have to comply with these onerous regulations? In my testimony, I said that we’ve reached a tipping point. Doctors just can’t do what they’re being asked to do with the resources they’re being given. The result of that is the rush to consolidation. It’s not like the consolidation wasn’t going on prior to this, but it has hastened it.

Interesting. "If they paid us more to do this, if we were somehow incentivized..."

I have a lot of my own issues with the Meaningful Use initiative, but are we to believe that the $6.1 billion incentive funds thus far disbursed are inadequate? Not to mention the market value of the federally subsidized REC resources engaged by providers?

BTW, the latest Data.gov update on Meaningful use attestations by vendor product.

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"HealthcareCommunities.org (HC) is a web-based knowledge management system that provides multiple means for the healthcare quality improvement community to share knowledge and contribute to each others’ QI work."

I was just assigned to become a Nevada HEN CoP site administrator (for our Hospital Engagement Network conrtact). Pretty nice. I'm not sure it gets a whole lot of traffic. Interesting stuff nonetheless. I started a Forum post on "workflow." We'll see if it gets any bites.

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UPDATE

"We have SNOMED, HL7, ASTM and the like, but little about how to design, build, and test systems. In other words, there is no handbook of clinical software engineering."

What's the real point of meaningful use?
August 06, 2012 | Jeff Rowe, Editor, EHRWatch

So here’s the question: Given the apparent difficulty – in terms of expense and the level of necessary collaboration – in achieving, say, the level of interoperability desired for MU Stage 3, what’s the point of the timeline? Perhaps more importantly, what’s the point of what lies beyond the MU timeline, which are the penalties for those Medicare providers who haven’t yet made the digital leap?

OK, that’s more than one question, but you see where we’re going. The HITECH incentive program is nicely structured to have three levels of implementation goals followed by a period of penalties for those who haven’t figured out how, or decided not, to achieve those goals. But it seems starkly clear that the complicated reality of health IT development and implementation renders that structure seriously unrealistic.

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I ASKED TO JOIN THE ASQ LEAN DIVISION LINKEDIN GROUP

Gotta love it. Thanks for letting me know. This year.
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More to come...

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...

Summary
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.

ANALYTICS WILL GET SIGNIFICANTLY EASIER

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*:

library(XML)
library(drc)
url <- "http://www.databaseolympics.com/sport/sportevent.htm?enum=110&sp=ATH"
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))
tail(golddata,10)
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),
     ylim=c(9.5,12),
     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,

http://www.databaseolympics.com/sport/sportevent.htm?enum=110&sp=ATH

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.

UPDATE, AUG 5TH

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.
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PALANTIR

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 www.data.gov. 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 Data.gov, 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).
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Can't wait to starting drilling down into this (below, installed on my iMac):

IN OTHER NEWS

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"?
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AUGUST 2nd UPDATE: NEW  BLOG

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.
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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.

CONTACT
Whitney Heins (865-974-5460, wheins@utk.edu)

This UTK alum is pretty proud.

IN OTHER NEWS:

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.

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gBench?

The Most Powerful Healthcare IT Job Network

• 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 CareerLadder.com Teen Spirit to a degree.

LATEST MU INCENTIVE $$$ UPDATE

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

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

Description
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.
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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.
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From my friends at Ober Kaler:

FIGLOIOZZI AND COMPANY BEGIN MEANINGFUL USE AUDITS AS CMS DESIGNEE

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...

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FROM THE LITTLE BLUE BOOK AND SHARECARE:
THE 2012 NATIONAL PHYSICIANS' SURVEY

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.

Interesting.

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

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HIE "CONSENT" UPDATE

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."

Really?


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?
Answer:

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?

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MY CRACKBOOK

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.
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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

ANOTHER 7-26 UPDATE: 
GAO REPORT (pdf) ON 2011 MEANINGFUL USE RESULTS

[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).

Nice.

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
By DR. WES

 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.
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NEWS ITEM: DR. BLUMENTHAL

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."

UPDATE: TWEETING WITH FARZAD

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

OK. And, your strategy for making this happen is precisely ______________?
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Relatedly, what are the latest developments over at ARCH-IT?

More to come...