Tracking #Ebola Effectively hindered thanks to #ICD10 (double) delay

This graphic

Offers a timely reminder that the US Government delayed a second time the implementation of ICD10 coding system that is used in the rest of the world

There is no code for Ebola in ICD9 - just a non-specific 078.89: Other specified diseases due to viruses which covers:

Disease Synonyms
Acute infectious lymphocytosis
Cervical myalgia, epidemic
Disease due to Alpharetrovirus
Disease due to Alphavirus
Disease due to Arenavirus
Disease due to Betaherpesvirinae
Disease due to Birnavirus
Disease due to Coronaviridae
Disease due to Filoviridae
Disease due to Lentivirus
Disease due to Lone star virus
Disease due to Nairovirus
Disease due to Orthobunyavirus
Disease due to Parvoviridae
Disease due to Pestivirus
Disease due to Polyomaviridae
Disease due to Respirovirus
Disease due to Rotavirus
Disease due to Spumavirus
Disease due to Togaviridae
Duvenhage virus disease
Ebola virus disease
Epidemic cervical myalgia
Infectious lymphocytosis
Lassa fever
Le Dantec virus disease
Marburg virus disease
Mokola virus disease
Non-arthropod-borne viral disease associated with AIDS
Parainfluenza
Pichinde virus disease
Tacaribe virus disease
Vesicular stomatitis Alagoas virus disease
Viral encephalomyelocarditis
Applies To
Epidemic cervical myalgia
Marburg disease

ICD-10 has one specific code for Ebola: A98.4 - Ebola Virus Disease
Clinical Information
A highly fatal, acute hemorrhagic fever, clinically very similar to marburg virus disease, caused by ebolavirus, first occurring in the sudan and adjacent northwestern (what was then) zaire.

Accurate tracking and reporting stop at the border of the United States

This is one of many examples of codes "missing" in ICD9 for conditions and care we are already delivering and dealing with

Connected Health and Accelerating the Adoption of #mHealth

I attended the Connected Healthcare Conference in San Diego yesterday
Accelerate mHealth Adoption: Deliver Results through Data Driven Business Models for End-User Engagement

Never has there been so much to play for in the mobile health landscape, a revolution is just round the corner with key players from the health care and consumer markets coming together to develop the mHealth industry. This Connected Health Summit will create a bridge bringing together hospitals, clinicians, providers, payers, software and hardware innovators, consumer groups and the wireless industry.

You can find the agenda here and the organizers will be publishing the presentations - there were many interesting insights

Andrew Litt, MD (@DrAndyLitt) (Principal at Cornice Health Ventures, LLC) opened the conference with a great overview of the industry and a slew of challenges and opportunities.

He sees our industry in Phase 1 - the Capture and Digitization of records
and we have yet to really move and explore Phase 2:

Move and Exchnage Data AND Analyze and Manage Data that is linked to Information Driven decision Making

And Phase 3:

Managing Patient Health

In our need to move from data to analysis and information he cited a statistic from a white paper: Analytics: The Nervous System of IT-Enabled Healthcare that sadly puts 80% of data in the EMR unstructured.
This is a fixable problem today with Clinical Language Understanding and we are seeing some results and a change in the industry to stop looking to doctors to be data entry clerks
He also cited Hospitals:

Hospitals are "remarkably inefficient organizations" - Andrew Litt #ConenctedHealth - #bigdata could help fix this
— Nick van Terheyden (@drnic1) October 14, 2014

Technology offers tremendous scope to not only fix these problems but get ahead of the problem (as is done in other industries like the Airline industry that has rebooked your flights before you even land and miss your connection). As he suggested could we use data to understand who is likely to develop a heart attack in the next 2 hours and try and change this outcome

But integrating mHealth into our workflow requires an mHealth Ecosystem:

mHealth needs an ecosystem that improves workflow and integrates data to reduce clinicians workload. This is why doctors and clinicians are resisting mHealth - they don’t like the change to the workflow that has little if any positive effect (for the doctor - they may have a positive effect for the individuals health) of reducing clinicians workload

Interesting comment on wearables and the perspective of doctors on these devices:

What bothers the doctor - mostly the people who are buying and using wearable fitness/activity trackers are the people that are young healthy fit and want to prove to (themselves/others) that they are young fit and healthy?

His graphic on Security and privacy was on the money:

Essential to balance Privacy of Health with interoperability but trust is the imperative
The stats he presented were troubling (at best)

• 96% - Percentage of all healthcare providers that had at least one data breach in the past two years
• 18 Million - Number of patients whose protected health information was breached between 2009 and 2011
• 60% - Proportion of healthcare providers that have had 2 or more breaches in the past 2 years
• 65% - Proportion of breaches reported involving mobile devices
• $50 - Black market value of a health record

The healthcare industry is under attack and is the most attacked industry today:

You might find these figures of the value of Healthcare data as it is valued on the black-market

Another interesting data point:

HIMSS records a total of 11,000 Healthcare Technology companies - less than 100 are large size and the balance of 10,900 are small business that are essentially capturing and scattering your data across many systems and data repositories...

Multiple other presentations and panelists that were all insightful. As always Jack Young (@youngjhmb) from Qualcomm Life Venture fund had some great insights - impossible to capture all of them but here are some:

Healthcare is moving out of the hospital into the home for many reasons but cost is a big driver:

and he suggested there was at least $1.5 Trillion in economic value as the industry shifts (shifting vs replacement?)

Many were surprised by his stat that users check their smart phone at least 150 times per day (just looking around my world this seems low) - in fact a quick check online suggests this is no longer valid and it is probably 221 times per day. Given this device is the one thing we will not leave home without and it now contains a range of sensors including:

• Accelerometer
• Gyroscope
• Magnetometers
• GPS
• Cameras
• Infrared
• Touchscreen
• Finger print
• Force
• NFC
• WiFi/Bluetooth/Cellular

We have the potential for more passive compliance with our patients (and as many stated in their presentations likely more accurate as self reported data is notoriously inaccurate)
He predicted a a 10x growth in wearables from 2014 - 2018 with 26% of this growth attributable to smart watches (I know hard to believe at this point but I think if you looked back 4 years ago the iPad had nothing like the level of penetration it does today)
iPad Growth Rate

I liked his assessment of the werable market place by researching the eBay Discount against the price of the new device:

and even worse for Smart Watches

I also presented “mHealth Reimbursement - Who Will Pay:
You can see it here at Slideshare or below:

mHealth Reimbursement : Who Will Pay? from Nick van Terheyden

Wearable Technology - An Exploding Segment

I attended a Wearble Technology conference today in Pasadena California: Wearable Tech LA

There was a wide range of technologies and innovations - everything from the mind monitoring by IntraXon’sMuse headband. Here’s their online demo video


One of the more interesting concepts takes the challenge we have all faced mastering the mechanics of walking, exercise, running and in some cases rehabilitation by placing sensors in the sole of shoes - Plantiga who have taken force analysis for our feet to a whole new level

The technology takes the static Force Plate sensor and turns into a continuous assessment 3-D tool offering an opportunity to apply this in specific sports and to help rehabilitate people who have been injured or have mechanical challenges (the side effect of capturing all this data is actually creating more comfortable shoes as they now have built in suspension and springs).

Better than this concept!

It might take a while to arrive in healthcare but in the meantime may well show up as another input device for the X-box or PS3 for a more realistic interface.

There was sensors to be placed all over the body for respiration, heart rate, muscle movement, acceleration/deceleration and even some to be ingested

A major challenge highlighted by several speakers facing all of the wearables genre was the issue of battery life

(and ironically it was the same problem I faced as I tried to capture and post social media)

The opening keynote was from Nadeem Kassam - CEO of BioBeats (Founder of Basis which is now an Intel company). His journey was one of classic rise from poor neighborhood in South Africa where he started his entrepreneur sporty selling oranges

He focused on three lessons - the first an essential learning point for everyone especially those facing healthcare challenges

Nothing is stronger than habit

He also suggested that those looking to succeed with innovation should:

• Look for innovation outside of your industry, and
• Don’t throw a big team or money at innovation

His story behind this was a classic one of engineers told to build a product who came back with his wearable watch that was a huge device that weighed down his arm and had a velcro battery pack under the arm!

He ended up finding his greatest engineers on Craigslist who’s references and Resume was a cardboard box full of devices that he had built.

The new concept of “Adaptive Media” which is bridging the divide between human emotion, data and the media we consume and should adapt to our mood based on our emotion. His new company has done some interesting research programs including an experiment with machines designed to allow people to hear their own heartbeat and have it set to music in Australia. When people heard their heartbeat for the first time it created a deeply emotional experience and many were moved to share very personal life stories.

They took this a step further and worked to gather heartbeats worldwide - a clever BIGData gathering exercise that amassed large quantities of rate, rhythm and details of millions of people around the world.


His overriding point was

We have to make health fun and engaging - merging it with entertainment to help people achieve what we all want - long tail of healthy life

There was a fascinating blend of the Entertainment industry and Hollywood and a slew of companies taking different approaches to these devices:

Epihany Eyewear tries to make wearables fashionable as well as functional (I’d say it not so much as fashion but blending into society)

Optivent with  powerful wearable glass - but no mention of the interface
They probably had the most fun concept video

Les lunettes d’Optinvent voient plus grand que les Google glass from Rennes, Ville et Métropole on Vimeo.

Enlightened design had the most impressive on stage display with a jacket that had lapels that constantly changing color

Janet Hansen - Founder & Chief Fashion Engineer, Enlightened Designs

Sporting her jacket with lapels that constantly changed color

Sports and Wearable

Given the excitement over the last month wight he World Cup it was fascinating to hear from Stacey Burr from Adidas who revealed that most if not all the teams were using technology to help them train and track in extensive detail - she suggested that there is not a single team or sport that is not using wearable technology in some form or another.

You can see some of the gear below

GPS enabled ECG/EKG monitoring Units plug into the back around the neck area

Paired with watches to offer players feedback

Digital insides of a ball used to sense how well it is struck

These are the professional versions used by major teams but Adidas is releasing commercial versions that will be available to the general public but lack the GPS capability and the analysis tools they offer

Surprisingly the leaders from a sports and country standpoint are Rugby and Australia and New Zealand who are "light years ahead" of wearable tech in sports

They are ahead in Psyching out their opponents too!

Sensoria demonstrated an exciting interactive future for sports and wearables where we challenge ourselves, other people and are coached by virtual assistants


Sensoria Fitness Shirt with Heart Rate Sensors from Heapsylon on Vimeo.

One of the highlights:Seeing Dick Fosbury of the "Fosbury Flop” Olympic Gold Medal Winner from Mexico 1968 and it turns out he is a Cancer Survivor, has an aneurysm and fully engaged in the intersection between healthcare and wearable technology

Neil Harbisson - Co-Founder, Cyborg Foundation

who was born totally color blind was definitely at the edge of wearable technology. He has an implanted device that turns color into sound and this is directly fed into his brain. He described that it took 5 weeks for the headaches to stop with this sudden input of data and then 5 months before it just became part of him and he now sees in color.
Here's his TED Talk: I listen in Color

He also has a permanent internet connection in his brain so people cane send him colors and images directly (he joked the address is private - but I did wonder given the ease with which spammers seem to find new addresses how he protects this destination from spam!)

I don't wear technology I am technology, I can't tell the difference between the software & my brain

The healthcare focused panel: Emerging Wearable 2.0 Health Platforms:

The furthest along and well know was probably Misfit wearables (Sonny Vu, CEO) who try and make sensors “disappear” but still simple sensors

OMSignal (Jesse Slade Shantz - Chief Medical Officer) was the most interesting as they are trying to change the monitoring from attached sensors to using fabric that can be loose fitting but can capture physiological information.

Breathometer (Charles Michael Yim - CEO) focus on analyzing your breath and have a range of products directed at health (over and above their simplistic alcohol breathalyzer available today) that assessed fat burning (using acetone) and asthma

NeuroSky (Stanley Yang - CEO) offer a system that other manufacturers can integrate into their wearables. Typically found in mobile phones or headsets

LUMO (Monisha Perkash - CEO & Co-founder) offering a discreet sensor that is designed to help improve your body posture and works as a tracker.

It's an exciting future with some fascinating technology to come - one thing for sure - with ubiquitous technology comes ubiquitous complexity and your voice will become an essential tool for successfully managing and navigating. Dragon Assisatnt is one of several tools built to assist in using and navigating technology that is reinventing the relationship between people and technology

Vaccines Don't Cause Autism - Vaccinate your Kids

It can be frustrating to be a clinician in the era of the internet and instantaneous availability of data especially when the reliability and accuracy is variable. But this is the world we live in and there is plenty of data showing that patients are accessing information in ever increasing numbers. The challenge has been helping patients filter the data for both relevance and accuracy.

Vaccination has been at the epicenter of a these challenges for some years - in fact long before the wide spread use of the internet thanks to a piece published in The Lancet in 1998  and unusually retracted. In fact the BMJ published a paper in 2011 declaring the paper fraudulent - as they noted in the discussion the lead author (now stripped of his medical degree and academic credentials) was clearly actively perpetrating the fraud

Who perpetrated this fraud? There is no doubt that it was Wakefield. Is it possible that he was wrong, but not dishonest: that he was so incompetent that he was unable to fairly describe the project, or to report even one of the 12 children’s cases accurately? No. A great deal of thought and effort must have gone into drafting the paper to achieve the results he wanted: the discrepancies all led in one direction; misreporting was gross. Moreover, although the scale of the GMC’s 217 day hearing precluded additional charges focused directly on the fraud, the panel found him guilty of dishonesty concerning the study’s admissions criteria, its funding by the Legal Aid Board, and his statements about it afterwards

Sadly despite repeated studies and investigations. Despite the retraction of the original article by the Lancet. Despite the other authors personally retracting the paper we still hear about a “link”. Sadly some high profile individuals continue to perpetrate the fraud (notably the model Jenny McCarthy and most recently the “reporter” Katie Couric).

I saw the posting by Aaron Carroll MD, MS is a Professor of Pediatrics and Assistant Dean for Research Mentoring at Indiana University School of Medicine (the Incidental Economist) last week when he posted this map of the real effects of this in Vaccine Preventable Outbreaks (click on the map button on the left if necessary)

In fact Dan Munro posted his own take on this piece: Big Data Crushes Anti-Vaccination Movement. As he sadly notes

Add a well known celebrity (or two) and the effects can be powerful, long term and hard to refute.

 And ss Dr Carroll notes the impact can be seen in the chart above:

• All of that red, which seems to dominate? It’s measles. It’s even peeking through in the United States, and it’s smothering the United Kingdom.
• If you get rid of the measles, you can start to see mumps. Again, crushing the UK and popping up in the US.
• Both measles and mumps are part of the MMR vaccine.
• Almost all the whooping cough is in the United States.

But the best part of this post is his accompanying video - included below - well worth watching the full 8 minutes

Expertly and accurately put.

Vaccinate your kids….please.

Treatment Creep in Medicine - sucking Decency out of Patients

This recent post on the Atlantic: How CPR Became So Popular reminded me of a piece I wrote some time back - Doctors Die Differently. As I said then:

Its not that doctors don't want to die, its just that they knwo they know enough about modern medicine to know its limits, importantly they have talked about this with their families as they want to be sure that no heroic measures will be used during their last moments in this reality

And the chart demonstrating the big discrepancy between what doctors want in life saving measures vs the general public pretty much said it all

So this piece in the Atlantic took it a step further - tracing the history of CPR from the 1960 at Johns Hopkins where the surgeons had

...successfully resuscitated every one of the first 20 patients they treated, 14 of whom (70 percent) survived without brain damage or other ill effects

But their source patients were not typical (young and mostly healthy) and when you extrapolate that out to an elderly population survival can fall to as low as 0% a variation in the effectiveness when performed in the real world
But it was Hollywood adn the media that pushed these procedures into the general awareness suggesting

...that two-thirds of all (fictional) cardiac arrests portrayed on ER (and other doctor shows) involved young patients who had suffered rare events like drowning or lightning strikes, rather than old people with heart disease (who account for 90 percent of cardiac arrests in real-life settings.....most of these fictional TV patients did well, unlike the vast majority of CPR recipients in real life

Dr Peter Benton was well known as all in life saving heroics



In fairness Hollywood was dramatizing some real life events - and they applied their pixie dust to this as they have to many other things.

But the problem remains and health care professionals need to help their patients understand their disease and make good choices, bearing in mind that heroics and life saving may well be a significant driver as it was for Stephen Jay Gould who was diagnosed with a rare and deadly cancer with a median survival of eight months...but as he said in his essay "The Median Isn't the Message".

this median survival means that one-half of patients die within eight months but the other half live longer. Most important, because the mesothelioma survival curve has a very long “tail,” a few lucky patients will live a lot longer

In his case his experimental treatment may have contributed to his 20 year survival past the original diagnosis...leaving a legacy of hope.

Social Network Sways Vaccine Compliance

via medpagetoday.com

Excellent article that demonstrates the challenges facing scientists and data. Despite the data clearly showing the benefits far outweighing the risks parents opinion and decision is swayed by "social norms"

As a society, we respect the privacy of healthcare decisions; however, if we are to sustain adherence to the recommended immunization schedule as a social norm, we need to learn how to empower immunizing parents to become vocal and talk with other parents, including prospective parents, about why they chose to immunize their children

Quite!

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Digital Health Needs To Be More Than Just Digital Data

This last week – the widely read Dr. Rob Lamberts lamented the usability of his Electronic Medical Record (EMR) software for his new primary care practice. It’s worth reading (here) as it highlights the larger systemic problem of EMR software generally and then specifically as EMR software is overlaid onto a new payment model.

In Dr. Lamberts case, a software solution – one that was built specifically around billing mechanics (namely ICD-9 and CPT “codes”) – was overlaid onto a new practice model that bills patients a flat monthly fee for “all-they-can-eat” primary health care. Almost all EMR/EHR software has been purpose-built to support billing as the primary function. Clinical data capture is the secondary objective – and the EMR/EHR software vendor landscape is 100% reflective of that priority (as is the entire system). At last count, there were over 600 EHR “vendors” and over 300 that had reported at least one doctor or practice that ”attested” to “meaningful use” with their software (a requirement for HITECH Act payment). To date, we’ve spent over $10B on “digitizing” health records.

I’m struggling to find the right analogy, but I imagine the effect Dr. Lamberts (and others) are feeling is similar to putting a V-8 engine onto a bicycle. Yes, you could (conceivably) engineer that solution – but why would you – and then why would you expect any kind of usable experience? You simply wouldn’t (unless, perhaps, you were Evel Knievel). Even Felix Baumgarten carefully employed a team of 300 (including 70 engineers and doctors) in his lone (and breathtaking) leap from the edge of space.

Forbes colleague David Shaywitz wrote more broadly (and brilliantly) about this in his piece earlier today: Handle With Care: Success of Digital Health Threatened by Power of Its Technology. This too is well worth worth reading as it relates to the “quick-fix” mentality that is pervasive in both our culture and our wheezing health care system. It’s everywhere – and short-sighted. For providers, let’s cram-down EHR solutions so that we can “capture” the downstream data/analytics that we so desperately need to control costs – with little interest, attention or concern to the consequence on the front-end patient dynamics (including both patient AND provider experience). For employers, let’s add “gamification” and “wellness” programs (with “behavioral economics” of course) to the HR/Benefits equation. While we’re at it – let’s automate low-acuity, primary care as much as we possibly can. There – all done. We’ve digitized, gamified and automated the whole mess.

The effect – as evidenced by Dr. Lamberts plight (and flight) – is to eject altogether. The fundamental hope (and risk) of this “direct-to-consumer” model is that personal (and fiscal) sanity will return to the private (often solo) practice of primary care. I’m not sure it’s the right hope (or exit), but I do understand the motivation and it is a worthwhile experiment because, more than ever, we need primary care physicians to stay engaged as we work through our health care transformation. I argue that Medscape’s chart on ”average” physician compensation highlights the broader dilemma – namely that primary care (the very entry point for health care) is the lowest paid.

We pay primary care in much the same way that we pay tellers at the bank. Tellers aren’t dead – nor is their survival at risk – but it’s tilting heavily toward the retail economy. So are primary care physicians. These are all the ”gatekeepers.” In fact, that may well be the exact path we’re on as we attempt to automate (and further minimize) the dynamics of primary care. Several companies (eg: Healthspot – which I wrote about in my CES coverage earlier this month) are building the physical Kiosk’s specifically targeting low-acuity, primary care. As a primary care physician – the assault is relentless – from every direction.

• Current payment rates that are unsustainable to a practice
• Further cuts to payment rates in the forecast
• Increasing demand for “accountability” (both regulatory and ACO’s)
• Complete subjugation by other specialties – where primary care is treated as the “funnel” or “filter” to higher-rate specialties
• Kiosk’s and eVisits as the final automation of primary care altogether (do we know who the doc-in-a-box is? Should we care?)
• Ever increasing volume as more people join the ranks of the “insured”

The technology overlay is simply the gamification and behavioral economics to support an increasingly desperate need for lower cost, but it’s unrelated to any metrics that support either better health outcomes or better care delivery. We don’t know. It’s entirely experimental.

All of which speaks to the huge need for more systemic changes around payment reform. As it stands today, the Affordable Care Act (ACA) does little more than tweak the current payment model. Yes, Accountable Care Organizations (a by-product of the ACA) are scaling broadly, but adding a risk component to the payment of care doesn’t fundamentally change the “fee-for-service” model – or mentality. As Paul Levy highlighted, ACO’s are “Neither Accountable nor Caring nor Organized”. Ouch. Yes, provider compensation will absolutely be tied to outcome (including things like “re-admissions”), but is that really the biggest, the best and only lever?

Don Berwick has suggested three ”triple aims.” We all know the first – better care, better health and lower cost, which is the ultimate goal, but there are two others. The second is:

1. We can get to better care, better health and lower cost – but we’re going to have to improve our way there.
2. The 1st Law of Improvement is that every system is perfectly designed to achieve the results it gets (ie: the current system is performing as built).
3. Improvement science is a system science – not an economic science.

The third is that there are 3 types of product improvements (and we need all 3):

1. Defect removal (ie: reducing hospital infections, fraud and waste)
2. Reducing costs (while leaving the customer the same or better)
3. Creating a new product or service (ie: a new model)

Don’s preferred example of a new model is the (Malcolm Baldridge National Quality Award winning) Nuka system in Alaska– but it’s not the only example. I wrote about the success of “worksite healthcare” last year. Using back-of-the envelope math – SAS (#2 for 2013 – and on the list of Top 100 Companies to Work for – 10 times) estimates that they save about $6M per year on healthcare costs. It’s not just lower cost either. They continuously demonstrate much happier, more productive employees – who also enjoy better health.

When describing either model, Nuka or worksite, there is almost no reference to digitized workflow. There is no reference to “gamification” or ”behavioral economics.” There’s also no reference to ”payment risk” or EMR “woes.” There is just improved healthcare – and the result is threefold. Better care, better health and lower cost. Triple aim. It does exist – and there’s even more than one model. We can get there but it’s through improvement. As Don Berwick suggests – that’s a system science – not an economic one. Unless and until we see that – I question how much healthcare transformation we’re actually getting. I’m just asking.

via forbes.com

Dan's right - it is not just about the data and coding. There are no quick fixes but listening to the clinicians and individuals enduring some of these changes is a good starting point and his point about primary care physicians is important - the key to helping patients manage their care. I would suggest that perhaps that what will happen is individuals will take on more of this role, supported by technology and clinical professionals (and not just doctors)

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Visualizing an e-Patient’s Medical Life History

via e-patients.net

What a great post from Katie McCurdy on the new age of medicine and the fact that the medical record needs to be more than single points of data recorded when we stop by a healthcare facility or clinical office.

Katie comes at this as an interaction designer so is able to create a coherent and easy to digest record which might be harder for others. But as she rightly points out

a patient-generated timeline, if that artifact makes the storytelling process easier for the patient & more coherent for the doctor, it adds a lot of value even if the doctor doesn’t want to take time to carefully analyze it.

Agreed - and as many of the e-Patients have demonstrated capturing and understanding data is helpful in the successful management of their care. And importantly as Edward Tufte has demonstrated repeatedly clear presentation of data is the key to understanding.

Doctors may not have the time to assemble the record in these formats and while there is a challenge presentation of multiple formats the process of capturing and documenting alone is valuable and likely to lead better understanding for the patient and the clinical care team.

What a great resource to have an engaged e-Patient who has a background in interaction design working on a project like this.

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