21 Bow Tie Salute to Farzad Mostashari

Like many in the healthcare IT industry, I was saddened by the announcement that Dr Farzad Mostashari (@Farzad_ONC) would be retiring. I would suggest as famed football legend Vince Lombardi said

"The strength of the group is the strength of the leaders"

And, for healthcare technology, Dr. Mostashari has been a great leader. I’ve outlined below some of the many contributions he has made to healthcare.

Dr. Mostashari joined the Office of the National Coordinator (ONC) in 2009, and has had a huge and positive impact on the implementation, development and overall perception of healthcare IT.  Personally impacted by the state of healthcare when his mother was admitted for arrhythmias, after having asked for the paper chart, he admitted;

I couldn’t even read the cardiology consult’s name

Perhaps this is one of the reasons he like me is a proud member of Regina Holliday (@ReginaHolliday) "Walking Gallery". This difficult, and highly personal, situation likely galvanized his vision as he took on the daunting tasks demanded by the role of the ONC. He inherited a department that had, in effect, been pushed over the edge of the luge and, whilst speeding wildly along this track, was expected steer a course that would deliver on a range of programs in record time:

• Meaningful Use of Electronic Health Records (EHR)
• Certification program for EHRs
• National Standards
• Grant programs
• Regional Extension Centers

And that was just what he knew about coming in. The team endured the challenges, weathered the storm in the "Office of No Christmas"

He rapidly earned a reputation as a leader who listened and was engaged.  He made many appearances and, although he may not have been the first, he was certainly an early adopter of social media and online engagement – clear indicators of his heartfelt passion to be part of the solution. As a customer service representative I recently encountered very astutely pointed out:

I can't do anything about the past, but I can help improve the future

Successes

It is hard to pick individual highlights from such an impressive record, but here's my list of Dr. Mostashari’s top 13 achievements and quotable/notable moments from his time in office:

1. Successfully delivering on the Stage 1 Meaningful Use, despite frustrations and the challenges of a fickle and change-resistant healthcare profession.  He gracefully offered a personal hand to help steer his colleagues:
   "Meaningful use is the best-we-could-make-it roadmap to prepare for delivery of higher quality care and mitigating some of the costs toward getting there, if it's a distraction we need to change it, and I want to hear from you personally."
2. Creating a viable technical assistance program that has touched many providers and hospitals through regional extension centers (REC).
3. Driving the successful adoption of electronic health records (EHRs) and electronic medical records (EMRs).
4. Interoperability (see note below on focus for the future)
5. Pushing for patient empowerment (He, like me, is a proud owner and runway model for the Regina Holliday Healthcare Collection).
6. As he said: "We’re on the right track to make meaningful use of meaningful use" 
7. ePrescribing
8. And as if to prove the point about his use of social media, this from his twitter feed: “We've made more progress with EHRs in the past 2 years then we have in 20"   
9. Championing the patient engagement he stated: "We cannot have it be profitable to hoard patient information"
10. Nailing the coffin shut on paper he said: "Once you close a paper file it's dead. You’re not able to move it or learn from it"
11. While this may not be his own personal quote but he applied cyberpunk science fiction, William F. Gibson famous quote to healthcare: “The future is already here – it’s just not evenly distributed.” by pointing out that we do have the technology - its just not being applied
12. Piloting Meaningful Use stage 2 criteria, which built on the success of stage 1, and pushed towards interoperability including standards for data sharing data, quality improvement, and quality measures that foster  patent engagement. As he put it: "We are using every lever at our disposal to increase the sharing of information" and "Patients need to care for themselves and become partners in their care"
13. Successfully weathering the storm of the controversial (or as he put it "headline grabbing") Health Affairs article based on data from 2008 that suggested that EHR technology was increasing the costs of healthcare.

The Future:

To the lucky individual taking the reins, I offer five suggested  areas of focus:

2. A friend once said to me: "You've put us on the horse, you might as well give us the ride." The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari's play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.

1. Continue the engaged and inclusive discussion with all the constituents and make social media a central part of that strategy both for ONC but also for the healthcare industry.
2. A friend once said to me: "You've put us on the horse, you might as well give us the ride" The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari's play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.
3. I must include a shout out for patient engagement. Nowhere else in the industry will you find such a large and untapped resource that is ready, willing – but perhaps not yet able to participate in the change. As I have stated many times:  when a doctor and patient are in a room, there is nobody, I repeat nobody, more interested in successful outcomes than the patient. Give them the tools and make them part of the solution.
4. Occasionally, the issue of Tort and Medical Negligence is raised, but it appears to have the "third rail" syndrome. Unless this is addressed, we will continue to see "defensive medicine" practiced. As I recently blogged in Science, Evidence and Clinical Practice, despite clear data that shows intensive monitoring causes more harm in normal care deliveries, we continue to see almost universal rates of this high-level monitoring.  While some may be attributable to the payment system, I believe a large part of this volume stems from the general inertia of and fear of litigation.
5. Above all - have fun. I made this point at every soccer practice when I was a coach. If you aren't having fun, there is little incentive to do well or, for that matter, to do at all. I know I am constantly amazed at the great fortune that finds me at this intersection of medicine and technology. I constantly have that feeling as if I paddled for the wave just at the right time:

"Surf's Up dude - ten foot waves of the Pier"

The Making of the 21 Bow Tie Salute

Dr Farzad Mostashari has been an incredible role model, a source of inspiration and a true visionary who has helped others see what the future of healthcare can look like. And so, in extreme appreciation of all that he has accomplished, I offer this 21 Bow Tie Salute.  

I was fortunate enough to have another wonderful role model, my father, take the time to teach me how to tie a bow tie, but for those of you wanting to learn the fine craft of tying a bow tie, instructions are included below (The 21 Bow Tie Salute was made with Real Bow Ties). 

Thanks Dad!

Here are some basic instructions:

News and sources include:

Healthcare IT News

ONC

Science, Evidence and Clinical Practice

A recent article on the The Difference between Science and Technology in Birth on the AMA site demonstrates the challenges we still face in getting clicnal practice influenced by science and data. Studies and data may show the path for best clinical practice but as the authors note there are multiple instances of the clinical community - in this case the OBGYN - either knowingly or unknowingly failing to follow the best practices

For deliveries in the US evidence tells us that fetal monitoring in low risk pregnancies has a deleterious effect - yet it remains standard practice in most settings to place external scalp electrodes and intrauterine pressure catheters

Although we still see external continuous fetal monitoring employed in many low-risk pregnancies, “as a routine practice [it] does not decrease neonatal morbidity or mortality compared with intermittent auscultation…. Despite an absence of clinical trial evidence, it is standard practice in most settings to place internal scalp electrodes and intrauterine pressure catheters when there is concern for fetal well-being demonstrated on external monitoring” [3].

 

They list several other standard practices including

• routing episitomy
• Use of Doula's
• Challenges with Epidurals

Reasons for these behaviors are varied but as the authors state:

Many well-intentioned obstetricians still employ technological interventions that are scientifically unsupported or that run counter to the evidence of what is safest for mother and child. They do so not because a well-informed pregnant woman has indicated that her values contradict what is scientifically supported, a situation that might justify a failure to follow the evidence. They do so out of tradition, fear, and the (false) assumption that doing something is usually better than doing nothing

Until we fix these basic issues there seems limited opportunity to implement intelligent medicine and real evidence or science based practices.

 

Introverts and Extroverts and How to Deal with them

In a great piece on FastCompany titled: Are you an Introvert or an Extrovert? What it Means for your Career, Beth Belle Cooper explores what she considered a binary position or bucket to put people in but discovers this is really a continuum and one that we as individuals don't sit at one spot all of the time

As she describes - it is an Ambivert Personality Scale Continuum

An important aspect to healthcare in our interaction with the ever expanding teams that contain wide variations of individuals

But in thinking about work, health acre and interactions the 12 tips for dealing with the different groups seemed like great advice all round

12 Tips for Dealign with Introvert

• Respect their need for privacy
• Never embarrass them in public
• Let them observe first in new situations
• Give them time to think don't demand instant answers
• Give them advanced notice of expected changes in their lives
• Give them 15 minute warning to finish what they are doing
• Reprimand them privately
• Teach them new skills privately
• Enable them to find one best friend who has similar interests and abilities
• Don't push them to make lots of friends
• Respect their introversion and don't try and make them into extroverts

10 Tips for Dealing with Extrovert

• Respect their independance
• Compliment them in hte company of others
• Accept or encourage their enthusiasm
• Allow them to explore and talk things out
• Thoughtfully surprise them
• Understand when they are Busy
• Let them Dive Right in
• Offer them Options
• Make physical and verbal gestures of Affection
• Let them Shine

I think what's interesting is most of us are in both camps at different times - the two lists seem like great advice all round

Technology as an Aid vs Hinderance to Doctors

A recent article in Becker Hospital Review:  Technology Should Aid Human Interaction: Q&A with Dr. Nick Terheyden, CMIO of Nuance featured some important points to make

Health IT needs to fade into the background. It needs to become part of the fabric of the office rather than the focal point, and then the interaction will change

• Using the tools to allow the clinician to focus on the patient not the technology
• Human beings deal in narrative and stories, patients want to tell their story and clinicians need the richness of the narrative to help guide medical decision making
• Remove the Physical Barriers to the clinicians patient interaction
• Healthcare is not the focus - the patient is
  

The key to our future and to the successful use of health IT will be turning the focus back on patient and the physician.

Interview with HealthTech Vision

I had the pleasure of speaking with Alex Welz of Health Tech Vision last week and he posted the interview here - or you can listen to it below

The importance of bringing intelligent voice interactions to Health IT especially as medical technology moves to into the Mobile world. It is an exciting time with technology offering real hope

Presenting at Health2.0

Excited to be presenting at Health2.0

http://www.health2con.com/events/conferences/seventh-annual-fall-conference/

There have been exciting innovations in Cloud based Intelligent Speech Understanding and our new development tool set is offering a way to help healthcare providers transform patient stories into high-value clinically actionable medical information. No more burdening clinicians with data entry tasks.

Florence

You can see it here integrated by by Sense.ly

We have a mobile development platform with more than 750 developers signed up already

The mobile health platform is good at delivering information but the interface can be challenging and capturing the medical decision making difficult using on screen keyboards and point and click methodology.

Mobile speech enablement offers tools that facilitate the navigation and human device interaction and includes capture and clinical understanding services that turn narrative into discreet actionable data to capture the clinical decision making

You can see a brief demo here:


Hope to see you at Health 2.0

Running out of Time

All truly great thoughts are conceived by walking
Friedrich Nietzsche

Don't walk behind me; I may not lead. Don't walk in front of me; I may not follow. Just walk beside me and be my friend
Albert Camus

I met Regina Holliday a while back at one of the many conferences that she attends:

At this conference she was there to present and was also creating a painting. Her reputation had preceded her and I was excited to meet her in person and hear her story first hand. I had seen some jackets at conferences and had discovered the story behind the Walking Gallery. An idea that came from a tragic story in a healthcare system that is broken











Back in 2011 a video was made featuring many from the gallery filmed at the Kaiser Permanente Total Health Center:


The Walking Gallery from Eidolon Films on Vimeo.

You can see her presentation on Slideshare here:

But there is nothing that could match the power of hearing this in person.

Regina offered to paint my story and it was months before I could pull together some photographs and sit down to articulate my personal journey in healthcare but that all came together a few weeks ago, almost in time for another walking gallery gathering. With so much going on Regina knew what she was going to paint but had not (as the picture shows)

 managed to download it quite yet

My journey to medical school and joining an honorable and privileged profession started when I was still at school and I remember the seminal moment that made me realize this was the pathway I wanted to take:

I was visiting my older brother in London we exited from Victoria rail station just as somebody had been run over by a bus. I watched as my brother pushed his way to the front of the crowd and he stooped own while very one watched - he was a doctor and knew what to do. As I stood on the sidelines watching I realized that I want to be doing rather than watching

I was a very young medical student and while I enjoyed medical school there was no doubting the fact that I was dealing with something that was really quite unique and challenging emotionally. Life and death was part of normal clinical activities and shortly after my 22 birthday I graduated

I have been heard to joke that the TV Series Doogie Howser was modeled on me as that was some years later - he was also the original blogger.

My Story

Running Out of Time

Practicing medicine in the United Kingdom in the national health service which while delivering great care placed an enormous burden on the people delivering that care. The environment was challenging, especially for a young junior doctor and I found myself questioning what I'd let myself in for. My first clinical job I worked 132 hours per week, I had Tuesday and Thursday evening off. At the time, that was the norm and all of my colleagues had the same work schedule as I did and I noticed that my senior colleagues not only had that working schedule but also took on more clinical responsibility. My weekends were hellacious, waking up on Friday morning and not finishing until Monday evening. I shared the work with a colleague and friend by the name of Niamh Anson. We would share the on-call work and split the activities, with one of us covering wards and the other covering the emergency department admissions.

The constant and chronic sleep deprivation took its toll and I repeatedly questioned the job I was doing and indeed whether I was even safe. The nurses proved to be our saving grace and several occasions when we made mistakes through simple tiredness they caught these mistakes and quietly corrected or prevented our errors. I don't remember a single time of being on call when I wasn't up most of the night and typically at leas every hour. Rarely did this not require a visit to either the ward or the emergency department. Many the time, I would walk from my living quarters to the emergency department angry at the system that would place such a burden on anyone and wondering if there was something wrong with me.

On one particular day my two team members were not at the hospital. Niamh was on holiday, one which had been booked many weeks ago but as is normally the case medical staffing had failed as usual to find replacement. By two in the afternoon, the emergency department had 17 patients waiting to be seen by me, there was a patient in intensive care on a ventilator that was having problems, and the cardiac care unit had a patient that was having a lignocaine reaction. I reached breaking point and called medical staffing, and told them I was quitting. Their reaction, humorous in hindsight but at the time not, was to tell me that my contract did not allow for me to quit. Fortunately the ward sister from the cardiac care unit intervened and quietly called my two attending's. The next thing I knew I received a call from one of them asking me to meet him in the emergency department. I thought my career was over and proceeded down to meet him expecting to be blasted and read the riot act. I was pleasantly surprised to find my two consultants there stuck into seeing patients and helping me out. One of them admitted all of the patients in the ED department while the other dealt with the patient on the intensive care unit in the coronary care unit.

Between us we were able to triage and treat all the patients by the end of the afternoon. Even now as I think back to that story I still find myself quite emotional about the experience and support from two outstanding individuals. They rounded it out by insisting that we went to the local pub for a drink (non-alcholic of course) and listened to me and provided counsel and support.

Sadly they were not typical of the senior staff in the health system and most took the view that they had suffered this level of overwork and therefore everybody else should experience the same. This was a recurring theme throughout my time as a clinician and I found most disturbing and many times very depressing.

If I am walking with two other men, each of them will serve as my teacher. I will pick out the good points of the one and imitate them, and the bad points of the other and correct them in myself.
Confucius

I remember vividly one instance where the attending surgeon I was working for heard that I was taking a sabbatical and thinking about leaving medicine. He started by saying that I was terrible shame, and I thought he was about to offer some guidance/support and thoughts about where the system is wrong and how I might cope with it. Sadly he proved to be similar to many of his colleagues and peers and felt that the system was wrong in allowing me into medical school. The system should of been better at weeding me out since there was clearly something wrong with me not with the system. He like many of his peers believed the baptism by fire, sleep deprivation and the general demeaning of junior doctors was an essential part of training and character building. As he put it, he had experienced this in his junior doctor days and he'd survived and done fine. What he failed to appreciate was that at the time he was practicing as a junior doctor, emergency call was typically a Porter coming to his door knocking on his door to tell him that somebody was "going off" and leaving a cup of tea for him. He would dress himself, drink his tea and proceed to the ward, where the patient had either died or survived, but there was very little that he could do to influence the outcome. My experience consisted of being surgically attached to an emergency page that would bark out at me at all hours, telling me to go to a ward or location in the hospital for an emergency resuscitation the could take anywhere from five – 60 minutes.

There is no easy walk to freedom anywhere, and many of us will have to pass through the valley of the shadow of death again and again before we reach the mountaintop of our desires
Nelson Mandela

My friend and colleague Niamh Anson

had many of the same experiences and like several of my colleagues elected to move away from the system leaving the NHS for Australia, perhaps hoping that this system would be more bearable. Sadly some years later she committed suicide as too many of my colleagues and friends do.

So my Walking Gallery Jacket:

As Regina described the picture:

The sky represents the never ending shifts as does the hour glass. The medical students and doctors are all standing beside me, also exhausted. My friend and colleague Niamh Anson jumping off the hour glass due to stress....

In what can only be described as a "stroke of luck" the painting of my jacket was caught on Fox 5 News doing a piece on the Walking Gallery (right around 00:24 -> 00:50 and around 01:28):

DC News Weather Sports FOX 5 DC WTTG
Or if the vide does not appear you can click this link



My jacket coming at number 227 - I hope we get all of these together one day.

If you don't like the road you're walking, start paving another one.
Dolly Parton

Like everyone else - I too have an oath to wear my jacket and use it as a tool to spread the word and effect change:

No one saves us but ourselves. No one can and no one may. We ourselves must walk the path
Buddha

7 Predictions for the Future of HealthIT

Great post: 7 predictions for the future of health care technology
I expect we are failing to imagine all the other opportunities that exist but makes some key points

Democratization of Medical Knowledge

For thousands of years, the science and art of medicine has been passed down from generation to generation under an apprenticeship model (it's called "a practice" after all). Today, we have an opportunity to leverage technology to make doctors' wisdom accessible to all. To date, we've published entire encyclopedias of medical knowledge, but they remain largely impenetrable by the mass audience. What's missing is useful, user-friendly information that guides healthy behavior

Quite right - gone are the days of the all wise and knowledgeable oracle ala "Wizard of Oz" for doctors

Consolidated Patient Information

It's only a matter of time before a platform emerges that can aggregate and safely store patient information in one place.

Not sure I agree that we are that close - we need truly shareable data but we continue to struggle to reach this key goal

Cost Savings from HealthIT

You bet!

we will need an efficient system to triage health queries and manage patients based on urgency, severity, and available capacity

And we will (and are) getting that! This company Sense.ly is a good example and leading this charge with virtual assistant technology

Medical Knowledge is Exploding

And it is only going to get worse (or should that be better) - its not just #bigdata that is driving this but the explosion of understanding, technological advances (genome, biome to mention a couple)

Focusing on the Patient

I have been saying this for a while - and Health technology is offering some new concepts to allow clinicians to focus on the patient vs the technology

The average doctor-patient encounter in the U.S. lasts seven minutes…..not surprisingly, patients often complain about their doctors' bedside manner

As this company EZDerm has shown with their innovative application has shown (what a great advert)

http://youtu.be/E6bU--8sszg

Technology can actually help foster a stronger culture of care in a fast-paced world – when visits are more efficient, doctors have more time to hold a hand, share a smile, alleviate anxiety, and talk with each patient…..Making patients healthier and happier

Original Geneticist who discovered BRCA1 Gene - Delighted with #SCOTUS ruling

The Geneticist Mary-Claire King who discovered the BRCA1 gene, says

she is delighted by the U.S. Supreme Court ruling that makes it illegal to patent it

and rightly so

Dan Munro reviews the decision in this piece on breaking the Myriad Monopoly

and he rightly pointed out that Mark Skolnick said in an interview in 2007

Q: "You [Myriad] said this test will one day be 100's of dollars. Why is it still $3,000? Why is it increasing?" Joanna Rudnick – film documentarian

A: "That's a good question and I think there's a point at which we have to start looking at decreasing the cost of the test." Founder and Former Myriad Genetics CEO – Mark Skolnick

Hmmm - now 6 years on and instead the price increases?

I don't think this will stifle innovation and what is often forgotten is much of the discovery and innovation was publicly funded - the original DNA project was publicly funded. This is a win for science

Hybrid Workflows Big Source of Errors for EMRs

Interesting study published by Pennsylvania Safety Authority 

Spotlight on Electronic Health Record Errors: Paper or Electronic Hybrid Workflows

What will not be a shock but still an important finding - hybrid workflows major challenge in EMR implementations creating much increased risk of errors

Credit Suisse Says Wearable Tech "The Next Big Thing"

Credit Suisse Says Wearable Tech "The Next Big Thing":

You bet - this market and area is going to explode

via Tumblr http://drnic1.tumblr.com/post/50916719025

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!

Posted via email from drnic's posterous

Four Reasons Doctors Worry About Social Media - #GetOverIt

I’m fortunate enough to spend a lot of time interacting with physicians, entrepreneurs, and investors on the bleeding edge of digital health – and it’s a consistently thrilling experience.

At the same time, the continuous exposure to the imaginative and the extraordinary can also be a bit deceptive.  Self-associating groups, as Sunstein has discussed, tend to adopt relatively extreme views, and it’s easy to envision this happening in Silicon Valley in general, and to digital health innovators in particular.

Consequently, it was probably healthy, and certainly arresting, to attend a breakout session on social media at recent a medical conference; the audience members were mostly practicing physicians, seemed passionate about patient care, and were explicitly interested in learning about social media.  Yet, most of the clinicians were not prepared to embrace it, and many were poignantly struggling to come to terms with a phenomenon they recognized as important, yet which viscerally troubled them.

Their concerns seem to fall into four categories, two involving patients, and two involving physicians.

1. Patients Receiving “Bad” Information

Many physicians described the challenges of dealing with patients who had retrieved wrong or incomplete information from the internet.  This turns out to be a remarkably common problem; doctors reported spending a lot of time undoing bad information.

The challenge was highlighted by the observation that 25% of Google searches for headache reportedly discuss brain tumors, even though such a diagnosis would be exceptionally uncommon.  The thought was that while physicians have learned during their training to appropriately weigh pre-test probabilities, patients have not, and are likely to fixate on extreme diagnoses rather than those that are most likely.

It seemed to me that “Dr. Google” upset many doctors not only because it complicated office visits, but also because it fundamentally altered the traditional doctor/patient relationship; as one physician said – verbatim – “I’ve lost my authority.”  It’s hard not to see this as a profound shift in perspective many experienced physicians understandably struggle to manage.

2. Patients Transmitting “Bad” Information

Many doctors in the audience were also visibly troubled by the ease with which patients could share “misleading” information, whether about medicine or the doctors themselves.

Despite the clear repudiation of a link between vaccines and autism, for instance, many patients continue to worry, a concern reportedly spurred on by an active internet anti-vaccine community.

Doctors were also fretting about the ease with which disgruntled patients could use the internet to besmirch reputations — one physician complained that when he Googled himself, the first links that came up were bad reviews he said represented a small number of extremely vocal patients.

3. Physicians Receiving Information Badly

While some senior physicians worried that young doctors might start to rely on tweets rather than peer-reviewed articles, it seemed that the most significant concern raised was the impact that the “internet culture” was having on the practice of medicine.  “We need to teach students that traditional values are still important,” one audience member said (again, verbatim), suggesting that students have become progressively less reflective.

The use of mobile devices – what consultants call “phone hygiene” – emerged as a particular source of physician aggravation.  Rounding residents would routinely look at the cell phones rather than pay attention to either the patients or the senior doctors, leading at least one doctor to prohibit the use of mobile devices on rounds – except for a 5’ phone break he built into the schedule, to accommodate what he described as the young doctors’ obvious addiction.

Another senior doctor, in a complaint evocative of this recent, much-discussed NYT article, noted that residents would routinely update her by text, rather than by phone.  She suggested this reflected a more general trend of young physician disengagement, evidently preferring to interact with devices rather than with other people.

4. Physicians Transmitting Information Badly

The ability afforded by social media to share information rapidly and broadly was another source of concern.  Many senior physicians worried young doctors might use social media in unprofessional ways – sharing things they shouldn’t, saying things they shouldn’t – potentially placing themselves and their institutions at risk.

In some cases, even seemingly innocent activities might be deemed inappropriate.  One young physician offered as an example a (medically-related) internet survey research project he wanted to do.  He said that while he could do this very easily, nearly instantly, and essentially for nothing using Google, he learned from his department this would violate institutional policy, and to conduct the research with the required protections in place would cost at least $25,000; naturally, the research has not progressed.

Moving Forward

via forbes.com

Great post by David on why clinicians should jump with both feet into the world of Social Media

Posted via email from drnic's posterous

Vaccine and autism: UK measles outbreaks and the Disgraced Mr Andrew Wakefield

Andrew Wakefield Tries to Shift Blame for UK Measles Epidemic

By Phil Plait

 | 

Posted Sunday, April 14, 2013, at 8:00 AM

943

432

Right now, in the UK, the outbreak of measles has reached epidemic proportions. Nearly 700 people have come down with the highly contagious disease in south Wales, and that number may double. Measles can cause a nasty rash and high fever, and in children can cause ear infections, encephalitis, and death.

Yes, death. Measles can kill.

So right now would be the worst of all possible times to give Andrew Wakefield precious front-page space on a newspaper to promote his incredibly dangerous antivax nonsense. Yet that’s exactly what the UK newspaper The Independent did.

Andrew Wakefield is the one who published a paper in The Lancet that started the modern fear of vaccines; the paper contained shoddy and subsequently disproven work in 1998 that contributed so much to the antivaccination movement of today. His work has been called fraudulent by the British Medical Journal, and the paper was so awful The Lancet retracted it. Time and again, MMR vaccines have been shown to have no link to autism, which is what Wakefield claimed. His serious professional misconduct led to his being struck off the official listing of doctors in the UK.

He is widely blamed for the recent outbreaks of preventable diseases. In recent years, vaccination rates have dropped, and we’ve seen outbreaks of pertussis (including in my home town of Boulder, with an infant nearly killed by it) and measles all over the world.

So why did The Independent give him a front page link on their site to air a diatribe blaming the government for the epidemic? That’s right, Wakefield had a press release saying the government’s interest was more in protecting the vaccine than protecting children, which is particularly rich coming from someone who was found to have used children unethically and with “callous disregard” in his own study. And The Independent ran his screed in its entirety.

The good news is, after getting blasted by skeptics like Ben Goldacre, the press release was taken down. If you want you can still read it the drippingly antivax site Age of Autism (read that site at your own risk). I do want to point out that in an irony so thick it’s palpable, Wakefield refers to vaccine researcher Paul Offit as a millionaire, using the old “follow the money” tactic. Really, Mr. Wakefield? Do you really want us to do that?

Back to The Independent, they also ran an article about Wakefield and vaccines along with the press release. To be fair, the article does condemn Wakefield, and if read carefully it does do a somewhat decent job overall of discrediting him. But it does have to be read all the way through, which is not something most people do these days (I expect the comments below to this very post will prove my point pretty well). And the headline with the article was, “MMR scare doctor: this outbreak proves I was right”.

Technically correct, but c’mon. That’s not a good synopsis of the article, to say the least. Martin Robbins at New Statesman dismantles the article thoroughly, and I strongly urge you to read that.

This kind of thing is not to be toyed with; people’s lives are at stake. Babies die due to these illnesses, easily preventable diseases if more people would get actual facts about vaccines.

My vaccinations are up-to-date. So are my wife’s. So are my daughter’s, including Gardasil. We understand the very small risks as well as the very large advantages of vaccinations. We also know the need for herd immunity.

You should understand them too. Don’t believe Wakefield. Don’t believe Jenny McCarthy. Don’t believe Age of Autism, or the Australian Vaccine Network, or any of those so-called “vaccine injury” groups. Talk to a real, board-certified doctor, and get their recommendation about vaccination.

What's happening in Wales can happen anywhere where vaccination rates are low. It's happening in my hometown. I sincerely hope it won't happen in yours.

Tip o’ the syringe to Rachael Dunlop and Ben Goldacre.

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via slate.com

Great expose slating the press given to the disgraced Mr Andrew Wakefield - he was struck of by the General Medical Council for perpetrating a fraud yet the Independent gave him ink on the front page over the weekend

Posted via email from drnic's posterous

Clinical Documentation Lifeblood of Healthcare

Awesome video put together showcasing the various aspects of clinical documentation and why it is so important to capture the complete patient story in narrative form



Putting all the details means capturing the diabetes and loss of consciousness

Everything from Assure and the ability to capture anywhere and the exploding area of mobile integration of voice and all the follow up in the back end for HIM

Science at Work - Number Of Early Childhood Vaccines Not Linked To Autism

A new study from the Centers for Disease Control and Prevention finds no link between the number of vaccinations a young child receives and the risk of developing autism spectrum disorders.

Jeff J. Mitchell/Getty Images

A large new government study should reassure parents who are afraid that kids are getting autism because they receive too many vaccines too early in life.

The study, by researchers at the Center for Disease Control and Prevention, found no connection between the number of vaccines a child received and his or her risk of autism spectrum disorder. It also found that even though kids are getting more vaccines these days, those vaccines contain many fewer of the substances that provoke an immune response.

The study offers a response to vaccine skeptics who have suggested that getting too many vaccines on one day or in the first two years of life may lead to autism, says Frank DeStefano, director of the Immunization Safety Office of the CDC.

To find out if that was happening, DeStefano led a team that compared the vaccine histories of about 250 children who had autism spectrum disorder with those of 750 typical kids. Specifically, the researchers looked at what scientists call antigens. An antigen is a substance in a vaccine that causes the body to produce antibodies, proteins that help fight off infections.

The team looked at medical records to see how many antigens each child received and whether that affected the risk of autism. The results, published in The Journal of Pediatrics, were unequivocal.

"The amount of antigens from vaccines received on one day of vaccination or in total during the first two years of life is not related to the development of autism spectrum disorder in children," DeStefano says.

The finding came as no surprise to researchers who study the immune system, DeStefano says. After all, he says, kids are exposed to antigens all the time in the form of bacteria and viruses. "It's not really clear why a few more antigens from vaccines would be something that the immune system could not handle," he says.

The study also found that even though the number of vaccines has gone up, the number of antigens in vaccines has gone down markedly. In the late-1990s, the vaccination schedule exposed children to several thousand antigens, the study says. But by 2012, that number had fallen to 315.

That dramatic reduction occurred because vaccines have become much more precise in the way they stimulate the immune system, DeStefano says.

“ The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, [researchers are] missing the opportunity to look at what the real causes are. It's not vaccines.

- Ellen Wright Clayton, professor of pediatrics, Vanderbilt University

Hardcore vaccine skeptics are unlikely to be swayed by the new research. But many worried parents should be, says Ellen Wright Clayton, a professor at Vanderbilt University who helped write a report on vaccine safety for the Institute of Medicine.

"I certainly hope that a carefully conducted study like this will get a lot of play, and that some people will find this convincing," Clayton says. That would let researchers pursue more important questions, she says.

"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are," she says. "It's not vaccines."

Autism Speaks, a major advocacy and research group, seems ready to move beyond the vaccine issue. Geraldine Dawson, the group's top scientist, praised the new study and says the result should clear the way for research on other potential causes of autism.

These include factors like nutrition, which can affect a baby's brain development in the womb, Dawson says. Other factors could include medications and infections during pregnancy, she says, or an infant's exposure to pesticides or pollution.

"As we home in on what is causing autism, I think we are going to have fewer and fewer questions about some of these things that don't appear to be causing autism," Dawson says.

via npr.org

More coverage and science referring to a recent study showing no link between vaccines and autism. This was covered in the SBM Site
The Final Nail in the Coffin - sorry if some of yo have trouble getting to the site as it appears to be having problems

As one commentator articulated

"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are, It's not vaccines."

If you are interested in a detailed analysis of the science and statistical analysis the SBM article is excellent. The analysis

They sliced and diced the data in a variety of ways looking for correlations and didn’t find any

And does an in depth debunking of the lack of science in the broadside from antivaccinationists who's fear mongering seems to date back to the widely and roundly debunked falsification of data by Andrew Wakefield that was described as the most damaging medical hoax of the last 100 years. He was struck of the GMC register and barred from ever practicing medicine in the UK.

As David Gorski in his title the study had not intended to disprove the relationship between the "toxins" used as part of vaccine make up. This study came as close as one can to disproving that relationship:

Which brings us to “too many too soon.” It appeared to be a “hypothesis” that was impossible to falsify, but DeStefano et al came about as close as it’s ethically possible to do to falsifying the hypothesis. No wonder that all that antivaccinationists are left with are calls for “vaxed versus unvaxed” studies and pharma shill ranting.

Science at work!

Posted via email from drnic's posterous

Great Guidance on Presenting

Awesome presentation on presenting.....

<iframe src="http://www.slideshare.net/slideshow/embed_code/17313548?rel=0" width="427" height="356" frameborder="0" marginwidth="0" marginheight="0" scrolling="no" style="border:1px solid #CCC;border-width:1px 1px 0;margin-bottom:5px" allowfullscreen webkitallowfullscreen mozallowfullscreen> </iframe> <div style="margin-bottom:5px"> <strong> <a href="http://www.slideshare.net/HubSpot/what-would-steve-do-10-lessons-from-the-worlds-most-captivating-presenters" title="What Would Steve Do? 10 Lessons from the World&#39;s Most Captivating Presenters" target="_blank">What Would Steve Do? 10 Lessons from the World&#39;s Most Captivating Presenters</a> </strong> from <strong><a href="http://www.slideshare.net/HubSpot" target="_blank">HubSpot All-in-one Marketing Software</a></strong></div>

Along with some key guidelines to help you put together really compelling presentations that will stick and people will remember. My favorite quote:

It's not a presentation, it's a performance

You can read the full article: 7 Lessons From the World's Most Captivating Presenters

• That includes specifics such as
• Start with paper not powerpoint
• Don't use bullet points
• Practice, practice, practice....and then practice again

Great stuff!

The bias of #bigdata - move towards Data With Depth #dwd #hcsm

This is a great presentation by Kate Crawford

Algorithmic Illusions: Hidden Biases of Big Data

interspersed with some nice visuals (a silhouette illusion - a Kinetic bistable optical illusion that lacks visual clues for depth - the spinning cat!) to make the point that big data. The point being there are ways we see data and potentially the wrong picture.

So the belief that with Big Data we get closer to truth does not necessarily hold true in all cases.

"With enough data, the numbers speak for themselves" Chris Anderson, 2008

Beep....beep....beep....back the truck up

Numbers don't speak for themselves. We (the people) and int he case of clinicians are the ones that interpret the data. Big data is not the complete answer - it is a form of

Epistemological blindness

So we ned to think about how we bring big data alongside small data.....hmmm perhaps taking the history and talking to the patient concurrent with big data analysis might provide a better, clearer picture

Move from #BigData to Data with Depth #dwd

You can watch it here or if the embedded version below:

<iframe width="1280" height="720" src="http://www.youtube.com/embed/irP5RCdpilc" frameborder="0" allowfullscreen></iframe>

Why EHRs Really Haven’t Made Us Healthier: A Response To Glen Tullman

Brian Klepper

Brian Klepper, Health Care Analyst and TDWI Writers’ Group

Glen Tullman

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.

Tagged as: Allscripts, CCHIT, CDA, Continuity of Care Record Standard, Electronic Health Record Technology, Glen Tullman, health information technology, HIMSS

via thedoctorweighsin.com

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

Posted via email from drnic's posterous

Accounting for Calories - Eat + Run

 

David Katz

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.

[See Soda, Calories, and a Full Accounting]

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.

[See Exercise: The Case for Counting What Really Counts]

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.

[See How to Take a Stand Against Junk Food]

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 caloric intake 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.

[See There's No Cure for Obesity]

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.

[See Diet Resolutions Worth Making]

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.

[See 5 Ways to Practice Portion Control]

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.

[See Nutrition Tips for College Students]

Hungry for more? Write to eatandrun@usnews.com 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.

via health.usnews.com

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.

Posted via email from drnic's posterous