- That includes specifics such as
- Start with paper not powerpoint
- Don't use bullet points
- Practice, practice, practice....and then practice again
Thursday, March 21, 2013
"With enough data, the numbers speak for themselves" Chris Anderson, 2008
Tuesday, March 19, 2013
Recently-fired Allscripts CEO Glen Tullman waxed progressive in a self-promotional Forbes article last week, describing the ways past and forward for electronic health records (EHRs) and health information technology (HIT). It may have been a way of trying to recover from a damning New York Times article that clearly illustrated the relationships between campaign contributions, influence over health information technology policy, and business success.
Tullman recalls building EHRs that moved many physicians away from paper and the errors it fosters. He calls out David C. Kibbe, MD as an example of the forces wanting to preserve paper and opposing EHRs, with quotes from a 2008 blog post suggesting that the current crop are “notoriously expensive,” “difficult to implement” and unable to demonstrate care quality improvements. He predicts that, in the future, the industry will leverage open platforms and interoperability, yielding new monitoring and management utilities that can facilitate better care at lower cost.
Tullman’s forecasts are hardly news, and there are two problems with his portrayals. The first is the dissonance between what he says now and actually did. Tullman became a multi-millionaire crafting products and policy that delivered intentionally costly, unfriendly and incompatible systems. Under his leadership, Allscripts products never embraced a national standard for health information exchange, even though those standards were available, or developed the capacity to seamlessly trade information with other systems.
As a Trustee of the Certification Commission for Health Information Technology (CCHIT), a quasi-governmental credentialing agency and offshoot of the Health Information Management Systems Society (HIMSS), he oversaw policies that favored large, established HIMSS members and set up roadblocks to innovation by technology startups. I testified on this topic to a Health and Human Services (HHS) panel in July, 2009. HHS subsequently rescinded CCHIT’s monopoly on EHR certification, and CCHIT’s Executive Director, Mark Leavitt, resigned shortly afterward.
Tullman’s strong support of and relationship with President Obama facilitated his role as one of the architects of the Meaningful Use (MU) subsidies. Those actions brought billions of dollars to EHR vendors between 2010 and now, but these EHR systems still can’t talk with one another. As I’ve described elsewhere, even while the health IT industry extolled the benefits that would come from easy sharing of health data, they nearly unilaterally resisted interoperability. (If you can’t easily move your data to another vendor’s platform, you’re less likely to make them your vendor.) The result is that our inability to seamlessly exchange health information continues to undermine our ability to coordinate care, costing America thousands of lives and hundreds of billions of dollars a year.
Tullman also paints Kibbe and the American Academy of Family Physicians (AAFP) as obstacles to HIT progress, when in fact it was Tullman and his EHR vendor colleagues who engineered the barriers to interoperability. The quotes by Dr. Kibbe are taken out of context and misrepresent him as an opponent of EHRs. In fact – and Mr. Tullman knows this – Dr. Kibbe has been in the vanguard of EHR use. He was the lead architect of the Continuity of Care Record (CCR) standard, the forerunner of the Consolidated Clinical Document Architecture (CCDA) which has become the standard of choice for MU data structure during health information exchange. When he was Executive Director of the American Academy of Family Physicians’ Center for Health Information Technology (AAFP CHIT), his campaigns resulted in a five-fold increase in the percentage of family physicians with EHRs, from 10 percent to 50 percent between 2003 and 2007. Today, he spearheads DirectTrust, an approach to securely and privately transfer health information by email, independent of platform. If anyone has moved health information generally and EHR technology specifically forward in this country to the common benefit, it is Dr. Kibbe. By contrast, Mr. Tullman has represented the special interest, blocking advances to make as much money as possible.
Physicians, purchasers and patients should take umbrage at Tullman’s article. Along with EPIC, Cerner, NextGen and other old guard EHR vendors, Tullman and Allscripts are directly responsible for most current EHRs’ outrageous costliness, lack of usability and interoperability, and their limited clinical decision support. Through their scale and influence over policy, they have effectively manipulated the EHR market, gouging purchasers and delivering marginally capable products. Health care costs more, and outcomes have suffered as a result.
Most Forbes readers won’t have enough health industry background to place Tullman’s comments into context. They are opportunism masquerading as good policy. Past performance is indicative of what we can expect in the future. Caveat emptor.
Nice piece responding the the disingenuous quotes and references taken out of context suggesting David Kibbe is against implementation of EHR's. HE like many of us is in favor but has long been an advocate of and vanguard of EHR use
Dr. Kibbe has been in the vanguard of EHR use. He was the lead architect of the Continuity of Care Record (CCR) standard, the forerunner of the Consolidated Clinical Document Architecture (CCDA) which has become the standard of choice for MU data structure during health information exchange. When he was Executive Director of the American Academy of Family Physicians’ Center for Health Information Technology (AAFP CHIT), his campaigns resulted in a five-fold increase in the percentage of family physicians with EHRs, from 10 percent to 50 percent between 2003 and 2007. Today, he spearheads DirectTrust, an approach to securely and privately transfer health information by email, independent of platform. If anyone has moved health information generally and EHR technology specifically forward in this country to the common benefit, it is Dr. Kibbe
Quite! Long standing advocate and unlike many of the commercial interests who spend much time, energy and resources blocking open access.
There remain challenges and the competing interests embedded in commercial incentives but to call out an icon in #HealthIT and unnecessary
Tuesday, March 12, 2013
One of the more titillating medical stories to make news recently is a study in the American Journal of Clinical Nutrition indicating that calorie intake in the United States has come down, and obesity rates have not. What makes this titillating, of course, is that it seems to suggest some great new mystery of energy balance. But I think we can account for this finding without revisiting laws of thermodynamics. We can, and we should—because there is real potential danger in abdication. If we don't account for these calories, others will.
For example, as I was indulging recently in one of my all-too-infrequent guilty pleasures, namely cuddling with my wife and watching American Idol, I was fascinated by Coca-Cola's latest commercial. This ad, brilliantly produced and polished as ever with Coca-Cola, invites us, essentially, not to worry and just be happy with the calories Coca-Cola serves.
The ad gives us a can of Coke, presumably 12 ounces, providing 140 calories. We are then shown the activities we can "enjoy" to burn up those calories. I trust everyone recognizes the activities are additive—you have to do them all to burn those 140 calories. And I trust those watching reliably do the math and reach the conclusion that it's roughly 37 minutes of physical activity all together.
Coca-Cola doesn't address how long it takes to drink those 140 calories, but we all know it's a matter of seconds. Nor does it look at the energy balance situation in reverse: You could replace the calories burned in 37 minutes of moderate activity by drinking just one 12-ounce Coke! And, of course, Coca-Cola doesn't even hint at a reality where most people who drink Coke drink more than 12 ounces and more than one, and where we can't get most people up to even 20 minutes of daily physical activity. Coke's own, happy ad indicates that if you drink two of these babies a day, you need well over an hour and a quarter of moderate physical activity to burn just those calories—to say nothing of any others you happen to consume.
No, in Coke's accounting for calories, it leaves those logical considerations to us. Because, of course, the company want this to be less about Coke, and more about our couches. If only we would get off the couch more, we could (presumably) drink Coke to our heart's content!
For now, we can leave aside other considerations—such as the quality of calories and the fact that Coca-Cola provides no nutritional value—aside. Let's get back to the new study. I'm sure folks at Coca-Cola love it, because it readily invites a "we're-doing-fine-with-calories-and-not-exercising-enough" interpretation. That's tailor-made to support Big Food's preferred answer to the problem of epidemic obesity.
So we need to account for those calories, or we invite Madison Avenue to do it for us. And we can.
First, some of the answer may well be a decline in physical activity. We have recent evidence that physical activity is being jettisoned ever more routinely from schools; that we sit more hours a day than ever before, and shorten our life spans as a result; and that sedentariness may now represent the leading cause, and certainly a leading cause, of years lost from life and life lost from years around the globe. This all suggests we should, indeed, increase our activity level. It does not suggest room for adding ever more Coca-Cola calories as we do so.
Second, I'm a bit surprised to hear that obesity rates have only kept rising. Haven't we been told from just the same kinds of studies that obesity rates had plateaued? Haven't we heard that obesity rates have actually declined in locations around the country? I am perennially frustrated by our tendency to forget about every prior medical study that made news every time a medical study makes news. OK, our calorie intake may have come down a bit. But so, I thought we had been told, had obesity rates. These two things fit together rather handily.
Third, there's the fairly obvious possibility of erroneous reporting. Getting accurate dietary intake information is notoriously difficult. We all tend to underreport our and overreport our physical activity. We also tend to underreport our weight and overreport our height. None of this is willful deceit; it's just human nature. We tend to spin everything to the positive, ourselves included, apparently.
We also know that in all survey research, participants have some tendency to tell the researchers what they want to hear. As our society has become ever more focused on epidemic obesity, it would be no great surprise if we were ever more inclined to tell, inadvertently, little white lies about our calorie intake.
Fourth, there's the fact that before the recent decline in reported calorie intake, there was a much bigger rise. The researchers tell us average food intake went up by some 314 calories per day between the early 1970s, and 2004. It has apparently gone down by some 74 calories per day since. But that means we've cut back less than a quarter of our new-age gluttony. If we're still eating more calories than we need, we won't be getting thinner any time soon—we'll just start getting heavier less fast.
Fifth, it takes time either to gain weight or lose it. If we really did only recently dial back our average calorie intake, then maybe obesity rates will follow. But we need day after day, month after month of consistently lower calorie intake before it shows up as more than a blip on the nation's scale.
And then sixth, and finally, what I think best accounts for a decline in calories, and no corresponding change in obesity rates: the bell curve. I'll explain.
We define "obesity," for better or worse, using the BMI (body mass index) and specific cut-points. A BMI from roughly 18 to 25 is "normal" weight. A BMI from 25 to 30 is "overweight." And a BMI greater than 30 is "obese."
Now imagine that the entire population does indeed reduce average daily calorie intake—and that average weights do come down a bit as a result. Won't all of this weight loss show up as a change in obesity prevalence?
Of course not! If normal-weight people become slightly leaner, there will be no change in obesity rates. If overweight people become less overweight, but stay in the overweight range, there will be no change in obesity rates. And if obese people become less obese but stay in the obese range, there will be no change in obesity rates. The only groups in the population likely to affect obesity rates are those right at the cut-points: those with BMI of just under, or just over 30. The former can gain a little weight and make obesity rates go up; the latter can lose a little weight and make obesity rates go down. Everybody else would have to gain or lose a lot of weight to affect obesity rates at all.
The data to tell us what percentage of the population has a BMI just north of 30 are available, but I couldn't get my hands on them while writing this. So, invoking the common bell curve distribution as a default, we may reasonably infer that weight is distributed across the spectrum from low to high, clustering around the mean. That suggests that only a very small percent of the population—well below 10 percent, certainly, can lose a bit of weight and affect obesity rates. The study in question, though nationally representative, is still based on samples of just thousands, and could readily be blind to such a relatively rare occurrence.
That will do for now. I acknowledge that the quality of calories matters, but so does the quantity. We cannot allow a seemingly small divergence in calorie and obesity trends to invite wild imaginings. Yes, we should be more physically active—but since it's far easier to out-eat exercise than to out-exercise all those tasty calories, we ignore the "calories in" side of the energy-balance equation at our peril.
We can account for the recent study with no great difficulty. We can certainly do so without rewriting any laws of physics. We can account for those calories, and need to do so—because the likes of Coca-Cola have already indicated how happy they would be to do it for us.
Hungry for more? Write to firstname.lastname@example.org with your questions, concerns, and feedback.
David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management, and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center, and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine.
Excellent piece reviewing the terrible state of obesity in our country and the impact that the food industry is having - focusing on the Coca Cola advert that tries to persuade people that enjoying a coke is worthwhile because you can do all these activities - all 37 minutes of them!
Its a simple equation - input and output. If you consume more calories than you output in the form of exercise and activites of daily living thenyou will gain weight
As David points out
We cannot allow a seemingly small divergence in calorie and obesity trends to invite wild imaginings. Yes, we should be more physically active—but since it's far easier to out-eat exercise than to out-exercise all those tasty calories, we ignore the "calories in" side of the energy-balance equation at our peril
By any other measure obesity is an epidemic and as I saw recently described the fast food industry as our generations version of nicotine and the smoking.