21 Mar 2014

45% of physicians say EMRs make care worse

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Post orginated from: http://www.healthcaredive.com/news/45-of-physicians-say-emrs-make-care-worse/232679/

Dive Brief:

  • A new study finds 45% of physicians believe EMRs are making patient care worse.
  • The research, according to marketing and research firm MPI Group and Medical Economics, concludes that Meaningful Use incentives aren’t enough to cover unexpected staffing expenses and lost physician productivity. In fact, 77% of the largest practices spent nearly $200,000 on their systems.
  • Findings also show that almost two-thirds of doctors would not purchase their current EMR system again because of poor functionality and high costs.

Dive Insight:

It looks like for too many doctors, their worst EMR fears have come true, proving to be expensive, a drain on staff and technically inadequate. And that is really bad news. After all, patients spend most of their time with doctors, not in a hospital with an IT staff on hand to address these issues. It’s even worse to hear that 45% of respondents to the study said that patient care is worse since implementing EMR. The health IT industry as a whole must do something to make doctors more comfortable with their EMRs.

05 Dec 2013

Updated healthcare.gov gets mixed reviews

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From Boston.com article by Kelli Kennedy – December 3, 2013

FORT LAUDERDALE, Fla. (AP) — Counselors helping people use the federal government’s online health exchange are giving mixed reviews to the updated site, with some zipping through the application process while others are facing the same old sputters and even crashes.

The Obama administration had promised a vastly improved shopping experience on healthcare.gov by the end of November, and Monday was the first business day since the date passed.

Brokers and online assisters in Utah say three of every four people successfully signed up for health coverage on the online within an hour of logging in. A state official overseeing North Dakota’s navigators said he had noticed improvements in the site, as did organizations helping people sign up in parts of Alabama and Wisconsin.

But staffers at an organization in South Florida and a hospital group with locations in Iowa and Illinois said they have seen no major improvements from the federal website, which 36 states are relying on.

Amanda Crowell, director of revenue cycle for UnityPoint Health-Trinity, which has four hospitals in Iowa and Illinois, said the organization’s 15 enrollment counselors did not see a marked improvement on the site.

‘‘We had very high hopes for today, but those hopes were very much quashed,’’ said Crowell. She said out of a dozen attempts online only one person was able to get to the point of plan selection, though the person decided to wait.

The site appeared to generally run smoothly early Monday morning before glitches began slowing people down. By 10 a.m., federal health officials deployed a new queue system that stalls new visitors on a waiting page so that those further along in the process can finish their application with fewer problems.

About 750,000 had visited the site by Monday night — about double the traffic for a typical Monday, according to figures from the Centers for Medicare and Medicaid Services.

Roberta Vann, a certified application counselor at the Hamilton Health Center, in Harrisburg, Pennsylvania, said the site worked well for her Monday morning but she became frustrated later when the site went down.

‘‘You can get to a point, but it does not allow you to select any plans, you can’t get eligibility (information). It stops there,’’ she said. ‘‘The thought of it working as well as it was didn’t last long.’’

In South Florida, John Foley and his team of navigators were only able to successfully enroll one of a handful of return applicants who came to their office before glitches started, including wonky estimates for subsidy eligibility. He worried about how they would fare with the roughly 50 other appointments scheduled later in the week.

Although frustrated, most were not deterred, he said.

‘‘These are people that have policies going away, who have health problems. These are people that are going to be very persistent,’’ said Foley, an attorney and certified counselor for Legal Aid Society of Palm Beach County.

Despite the Obama administration’s team of technicians working around the clock, it’s not clear if the site will be able to handle the surge of applicants expected by the Dec. 23 deadline to enroll for coverage starting at the beginning of the year. Many navigators also say they’re concerned the bad publicity plaguing the troubled website will prevent people from giving the system another try.

‘‘There’s a trust level that we feel like we broke with them. We told them we were here to help them and we can’t help them,’’ said Valerie Spencer, an enrollment counselor at Sarah Bush Lincoln Center, a small regional hospital in the central Illinois city of Mattoon.

Federal health officials acknowledged the website is still a work in progress. They’ve also acknowledged the importance of fixing back-end problems as insurers struggle to process applications because of incomplete or inaccurate data. Even when consumers think they’ve gone through the whole process, their information may not get to the insurer without problems.

‘‘We do know that things are not perfect with the site. We will continue to make improvements and upgrades,’’ said Julie Bataille, communications director for the Centers for Medicare and Medicaid Services.

In less than an hour Monday, Starla Redmon, 58, of Paris, Ill., was able to successfully get into a health plan with help from an enrollment counselor. Redmon, who juggles two part-time jobs and has been uninsured for four years, said she was surprised the website worked so well after hearing reports about its problems.

‘‘Everything she typed in, it went through,’’ said Redmon, who chose a bronze plan and will pay about $75 a month after a tax credit. ‘‘It was the cheapest plan I could go with.’’

28 Nov 2013

Telemedicine consults may reduce errors at rural ERs

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Reuters Health article by Genevra Pittman, Nov 25, 2013

Emergency rooms in rural areas don’t see many very sick or badly injured children each year. When they do, bringing in a pediatric critical care specialist by videoconference to help with treatment could prevent errors, a new study suggests.

Researchers found rural ER doctors made errors in administering medication – such as giving the wrong dose or the wrong drug altogether – just 3 percent of the time when they used so-called telemedicine to connect with a specialist.

That compared to an 11 percent error rate when local doctors talked with a specialist by phone and a 13 percent error rate when they didn’t consult with a specialist at all.

“We know that we make a difference by being able to see the patient,” Dr. James Marcin said. The study’s senior author, he is on the telemedicine team at the University of California Davis Children’s Hospital in Sacramento.

Comparing telemedicine to a phone consultation, Marcin said, “It’s the difference between the doctor coming in to do an office visit with you with his or her eyes closed, versus with his or her eyes open.”

During a telemedicine conference, specialists also tend to get more involved in the patient’s care and may be more likely to speak up about their treatment opinion, Marcin told Reuters Health.

For the new study, he and his colleagues looked at data on 234 children with severe illnesses and injuries who were seen at one of eight rural hospital ERs in Northern California between 2003 and 2009.

Those rural hospitals were small and the only hospital in their vicinity.

The ERs were participating in a larger study on telemedicine. Rural doctors could use a video conferencing unit to consult with pediatric critical care specialists like Marcin whenever they chose.

Telemedicine was used for 73 of the sick or injured children. For another 85 patients, local doctors consulted with a specialist over the phone. For the remaining 76 kids, they did not ask for help.

Local doctors gave 72 percent of all children at least one medication while they were in the ER, according to the findings published in Pediatrics.

Among cases when doctors used telemedicine, they gave children a total of 146 medications. Five of those were the wrong drug for the child’s condition or were administered incorrectly.

In comparison, there were 18 errors out of 167 medications given to children when doctors consulted a specialist over the phone. And there were 16 errors out of the 128 drugs administered when there was no consultation.

“The amount of information that you can gather in a telemedicine consultation is typically much richer than what you can gather from a telephone conversation,” Dr. Alejandro J. Lopez-Magallon said.

“Also, the level of interaction with the remote care team widens because you’re not talking with a single person on the other side – you can interact with the remote physician or physicians and nursing staff, support staff and the patient and family themselves,” he told Reuters Health.

Lopez-Magallon studies telemedicine at the Children’s Hospital of Pittsburgh of UPMC but wasn’t involved in the new study. He said it “supports, in this case, the use of this technology to improve patient care.”

The researchers could not tell whether fewer medication errors meant sick and injured children fared better in the end. They also didn’t know if doctors administered the drugs before or after conferencing or calling a specialist.

Although this is one example of telemedicine, the researchers said it is more often used during outpatient visits – such as to connect with a specialist from a remote primary care doctor’s office.

“Telemedicine is becoming more and more mainstream, compared to what it was a decade back,” Dr. Madan Dharmar, the new study’s lead author, told Reuters Health. He is also from the UC Davis Children’s Hospital.

Marcin said in his team’s experience, telemedicine consultations cost about $2,000 each, including the price of the equipment.

But if the consultations can save a couple of emergency helicopter transfers to a larger hospital, they will more than pay for themselves, the researchers said. They are currently working on those cost analyses.

21 Nov 2013

ObamaCare will create healthcare jobs

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Article by Ira E. Shapiro, The Hill blog, November 14, 2013

Despite the negative attention Obamacare has had recently, Obamacare will also help create many new jobs in the healthcare arena in our country due to the shortage of coders in the healthcare industry.

Under Obamacare, roughly 40 million new patients will enter our healthcare system and that will create the need to code hundreds of millions of new charts each year. Under ICD-10 productivity estimates, a coder will take half an hour to code an average outpatient chart and an hour on average to code an inpatient chart. Think of the millions of new coders and billers that will have to be hired within the healthcare industry over the next 5 years. This will make medical coding one of the fastest growing professions in the country.

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problem, a list maintained by the World Health Organization.

Secondly, the new medical coding requirements under ICD-10 are much more specific and requires more in-depth knowledge from a medical coder, such as subject matter expertise in medical terminology, anatomy, physiology, pharmacology, and pathophysiology. This paradigm shift in the elevation of a medical coder’s importance to the revenue cycle of a healthcare facility and level of expertise required, along with an aging medical coding population is causing a significant shortage of coders and billers in healthcare.

Furthermore, it is expected that productivity will drop by at least 50 percent for coders and billers in the new world of ICD-10, as it happened in the other countries as they transitioned into ICD-10. The increased workload may even have a more severe impact on productivity here in the U.S. because our ICD-10 is different and more rigorous as we will code for reimbursement, different from other countries that are single payer systems. Even under ICD-9 today, which is less complex, there is a severe shortage of coders and this will be magnified by ICD-10.

The Affordable Care Act has helped create a great opportunity for many people who need to work remotely because of its flexible nature and many can work from home. An example would be wounded warriors, the unemployed, returning veterans and spouses, single parents, high school graduates who don’t want to go on to a degree program, all whom are great candidates for a career in medical coding. Even other existing healthcare professionals and clinical people who are interested in a more administrative role would be interested in this career. It will pay very well, as it is predicted that a new medical coder in ICD-10 with no experience will command between $45k and 60k on average. No college degree required.

The biggest challenge from ICD-10 will be the vacuum created by the huge shortage of talent. Medical Coders, clinical documentation specialists, and other health IT professionals will all be in great demand. Intended or unintended, we have the Department of Health and Human Services and the Obama administration to thank for all these new job possibilities in healthcare.Despite the negative attention Obamacare has had recently, Obamacare will also help create many new jobs in the healthcare arena in our country due to the shortage of coders in the healthcare industry.

Under Obamacare, roughly 40 million new patients will enter our healthcare system and that will create the need to code hundreds of millions of new charts each year. Under ICD-10 productivity estimates, a coder will take half an hour to code an average outpatient chart and an hour on average to code an inpatient chart. Think of the millions of new coders and billers that will have to be hired within the healthcare industry over the next 5 years. This will make medical coding one of the fastest growing professions in the country.

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problem, a list maintained by the World Health Organization.

Secondly, the new medical coding requirements under ICD-10 are much more specific and requires more in-depth knowledge from a medical coder, such as subject matter expertise in medical terminology, anatomy, physiology, pharmacology, and pathophysiology. This paradigm shift in the elevation of a medical coder’s importance to the revenue cycle of a healthcare facility and level of expertise required, along with an aging medical coding population is causing a significant shortage of coders and billers in healthcare.

Furthermore, it is expected that productivity will drop by at least 50 percent for coders and billers in the new world of ICD-10, as it happened in the other countries as they transitioned into ICD-10. The increased workload may even have a more severe impact on productivity here in the U.S. because our ICD-10 is different and more rigorous as we will code for reimbursement, different from other countries that are single payer systems. Even under ICD-9 today, which is less complex, there is a severe shortage of coders and this will be magnified by ICD-10.

The Affordable Care Act has helped create a great opportunity for many people who need to work remotely because of its flexible nature and many can work from home. An example would be wounded warriors, the unemployed, returning veterans and spouses, single parents, high school graduates who don’t want to go on to a degree program, all whom are great candidates for a career in medical coding. Even other existing healthcare professionals and clinical people who are interested in a more administrative role would be interested in this career. It will pay very well, as it is predicted that a new medical coder in ICD-10 with no experience will command between $45k and 60k on average. No college degree required.

The biggest challenge from ICD-10 will be the vacuum created by the huge shortage of talent. Medical Coders, clinical documentation specialists, and other health IT professionals will all be in great demand. Intended or unintended, we have the Department of Health and Human Services and the Obama administration to thank for all these new job possibilities in healthcare.

14 Nov 2013

EHR Interoperability Remains Elusive

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John Commins, Senior editor, HealthLeaders Media, November 8, 2013

A lack of standards, privacy concerns, and proprietary and competition issues are just a few of the hurdles hampering the interoperability of EHR data among participants in health information exchanges.

Healthcare providers have made solid progress over the last decade building in-house electronic health records systems to share patient data within their networks. However, interoperability with outside providers and payers remains a significant barrier, according to eHealth Initiative’s 10th annual survey of health information exchanges.

Three-quarters of the nearly 200 eHI survey respondents said they’ve had to build numerous time-consuming and expensive interfaces between different systems to facilitate information sharing, including 68 organizations that said they had to build 10 or more interfaces with different systems. More than 140 respondents cited interoperability as a pressing concern.

Jennifer Covich Bordenick, CEO of the nonprofit, independent eHI, says the results of the survey are “mixed,” but adds that it would be a mistake to say that no progress is being made.

“If you look back five years you can see huge leaps in progress, but when you are looking year-to-year it is very slow. It is hard to look at these things in such a small period of time,” she says. “The type of problems we are having now is a sign of moving in the right direction. These issues wouldn’t have arisen five years ago because we didn’t have enough knowledge or we weren’t connected enough. Now we’re having connection issues, which is a good thing, whereas before we were just trying to convince people that they should do this.”

Bordenick says the hurdles in front of interoperability aren’t necessarily technical.

“There are proprietary and competition issues where people don’t want to share data with other organizations,” she says. “While we are all focused on the patient there are a lot of concerns that competitors are going to use their data to their advantage. So competition is one barrier and the other is standards.”

“We talk about standards all the time,” she says, “but really requiring standards on some of these simple areas would be helpful because right now you have a lot of systems that are proprietary. You have vendors who don’t necessarily want to interface with their competitors. So you have competition both with the groups with data, and completion just with connecting. There are all kinds of different politics involved here.”

To her surprise, Bordenick says the survey also shows that many HIEs have not yet developed ways to allow patients to enter or view their own data in the health exchanges. As part of the federal EHR Meaningful Use Program, patient engagement is a critical step for providers looking to receive incentive payments for using EHRs.

This could change in future years, as 102 organizations reported that they have plans to offer patients access to their data. However, only 31 organizations currently offer patients access to their information. Even simple patient engagement services, like tools for managing appointments or prescriptions, are rare Bordenick says.

“I would love to know what people in the field think about this,” she says. “It’s not clear why it’s not moving. Is it because somebody else is doing it? Are the exchanges relying on providers, the individual doctors? Somebody has to be doing it. So, is it that we don’t know who is doing it or is it that they’re not doing it because of privacy concerns?”

“While it’s a little disheartening to see such low patient engagement, overall I think we’re in a better place than we were last year. Awareness around healthcare reform has helped build the business case for data sharing and engaging consumers.”

Bordenick rejects suggestions that the federal government step in to play a greater role in setting interoperability standards. “The last four years have shown us that HITECH has done some wonderful things and Meaningful Use has pushed the envelope, but it has to come from the market,” she says.

“The more that customers or consumers or providers [push] for these connections, the more likely it is that vendors are going to do it because we have the capability to do it. Again, it is not about not having the capability. It’s about everyone having the same desire to connect.”

07 Nov 2013

3 in 4 Patients Want E-mail Consultations with Doctors

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From Health Leaders Media article by Ryan Chiavetta, November 1, 2013

Research reveals a large discrepancy between how parents say they would like to communicate with pediatricians and how they actually do communicate with doctors. Three quarters (77%) of parents said they would seek out email advice from their doctors, but only 6% said that they are actually able to communicate with their doctors this way, a study released by the C.S. Mott Children’s Hospital National Poll on Children’s Health has found.

How physicians practices are accommodating the growing patient demand for e-mail consultations involves settling on a reimbursement strategy that makes financial sense and resolving questions about patient privacy concerns.

The study highlights the providers’ concerns which revolve chiefly around how they will be paid for providing e-mail consultation services. Specific financial concerns noted are the variable nature of reimbursement for e-mail consultations, rather than the established ones for office visits, and the costs of implementing privacy and security systems for the communication exchanges.

A Time-Intensive Task
Matthew M. Davis, MD, MAPP, one of the authors of the study, said that providers consider carefully whether and how it is appropriate to charge patients for electronic availability due to the time it takes to review information and respond to an e-mail, rather than the instant access coming from a telephone call.

“When I receive an e-mail from a patient, I have to consider that patient’s relevant past history and recent history of illness, diagnostic options and what’s the best course of action,” said Davis. “That’s not a simple thing to manage in all or even most circumstances. So that’s where I think physicians are starting to think that having some expectation of payment for an e-mail consultation would be reasonable.”

How much patients are willing to pay for the service, may not meet physicians’ expectations. Half of the parents surveyed (49%) said they believed a co-pay for an email consultation should be less than a co-pay from an office visit and nearly half said e-mail consultations should be a free service.

Healthcare providers, however, are finding ways to work around these cost issues. Davis notes two ways that providers are working around the co-pay obstacle. One is a bill-as-you-go system that focuses on the provider tracking the e-mail exchanges and billing accordingly. The method hasn’t proven to be popular, as it is already difficult to bill for telephone consultations, and billing per e-mail might cause patients to be hesitant to contact or follow up with providers.

A much more successful method is to charge a fee for e-mail services that comes as a package, Davis says.

“Let’s just charge a general service fee to make certain that patients who want to have this service can buy it essentially as a bundled package, and just go ahead and use it if they have that particular service… That allows them to use the service as they need to whenever they need to, and pay a set flat rate accordingly.”

One provider that has already started using this approach is Group Health Cooperative, a non-profit healthcare system based in Seattle, WA, which currently runs a successful e-mail consultation service, covered by a fee included in the patients’ premium.

Matt Handley, MD, Associate Medical Director of Quality & Informatics at Group Health Cooperative is one of the group’s many physicians who uses e-mail to communicate with his patients. He says the this payment structure enables GHC to maintain financial feasibility.

A Cost Cutter
Since in-person visits carrying a higher cost than e-mail consultations, Handley says the organization has been able to trim practice costs.

Davis also views e-mail as a cost cutter for medical practices, mainly because it allows doctors to focus on their most complex patients who need to visit the office in order to be properly treated. “We need the patients who have the more minor complaints taking care of themselves or using other modes of care that may not necessarily involve us,” Davis said.

“A patient who may have cold symptoms should probably stay at home and use simple home remedies and not necessarily come in for a visit that day. If an e-mail note about those cold symptoms can help a doctor or a nurse tell a patient ‘you don’t need to come in today,’ that appointment slot is still open for that patient who may have a worsening of their heart disease or diabetes that day.”

E-mail in Boutique Practices
Traditional health systems aren’t the only ones using e-mail consultations. Choice Physicians is a concierge medicine practice that utilizes electronic messaging. Tiffany Sizemore-Ruiz, D.O., one of the co-founders of the practice, says that an e-mail consultation fee is built into the $1,500 retainer fee patients pay when they sign up.

Choice Physicians has a much smaller patient base than traditional physicians practices, so adding the service in the retainer fee is the only payment needed to finance the service.

“This is a 500−600 patient practice,” said Sizemore-Ruiz. “So if you do the math, and you take the $1,500 and multiply it by 500 patients, that $750,000 a year. I don’t need an extra $15−$20 to do an e-mail consultation.”

Sizemore-Ruiz says she is available for her patients 24/7, and with her smaller patient base at its current size, is able to answer all the e-mails that come her way.

For a larger practice such as Group Health Cooperative, it’s a team effort to keep up with patient e-mails. Increased workload was cited as an initial concern, but at GHC in Seattle, everyone has to come together to make sure all the patient inquiries are met, with the bulk falling to the primary physicians.

“A percent are answered by other members of the team, usually around a quarter to a third, and that’s things like ‘when did I last have my tetanus shot?’ But two-thirds to three quarters are answered by their doctor,” said Handley.

Privacy Matters
Privacy is another element that is vital to the e-mail consultation process, and it’s an area of concern that Davis, Sizemore-Ruiz and Handley all take seriously in their practices.

“We actually share their whole health record online with them so they can see their immunizations, medications, [and] make appointments online,” said Handley. “It’s much more secure than a paper chart. We do that in a compliant way that meets all the industry standards for privacy.”

“There are HIPAA-compliant e-mail companies that you can use and you can also password protect the e-mail and the patient also has a password,” said Sizemore-Ruiz. “Also in our particular electronic medical records system, we can send e-mails through our EMR, which is HIPAA-compliant.”

Patient demand for email consultations is clearly growing, but how quickly remains to be seen.

“I don’t know how quickly this will move,” said Davis. “There is such high patient expectation and demand that I think the opportunity is there for physician practices and health plans to try to sort this out sooner rather than later and capture the appeal of this particular way of interacting with physicians that patients are obviously seeking.”

31 Oct 2013

When Smartphones Do Dumb Things

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Mobile health apps are slowly revolutionizing patient care, but occasionally the revolution takes a left turn into lunacy and feeds a hypochondriac’s worst fears.

Article by Paul Cerrato, InformationWeek October 28, 2013

What are we to make of the Owlet Baby Monitor, which attaches to a baby’s sock and measures heart rate, skin temperature, blood oxygen levels, sleep quality and more, and sends the data to your smartphone?

“This is an invitation to craziness,” says Kenneth, Bromberg, MD, chairman of pediatrics at Brooklyn Hospital Center.

Bromberg goes on to say in a recent Wall Street Journal article that there’s no medical or safety reason for the device: “It will make [parents] neurotic and anxious. I don’t see how any new parent with that gadget won’t be driven insane.”

It’s only natural for new parents to fret about the well-being of a newborn, especially if it’s the first child, but as Bromberg points out, it’s unlikely they’ll find peace of mind monitoring a long list of vital signs on their smartphone. You might make a case for this kind of monitoring for a newborn suffering from some sort of chronic disease, but not for a normal child.

Devices like the Owlet are symptoms of a more global social disease: The medicalization of everyday life, a growing obsession among the worried well in an affluent nation. Men over a certain age no longer have a normal, age-related decline in libido, they have erectile dysfunction. Restless or poorly disciplined children no longer need firmer parent supervision; now they have attention deficit disorder. And, of course, stressed-out office workers with insomnia are suffering from a sleep “disorder” requiring prescription medicine.

Several social critics have put the blame for such medicalization of life’s everyday ups and downs on the pharmaceutical industry, which seems to always have a new medication to solve the problem. Now some mobile health developers are following this same path, seeing opportunities to cash in on the nation’s hypochondriacal tendencies.

Fortunately, most mobile health apps and devices take the high ground, concentrating on monitoring parameters that matter to people who really need them. Countless diabetics have benefited from blood glucose meters that link to their smartphones. Home-bound patients with congestive heart failure are now feeding body weight readings into mobile devices to send to their physicians. A new app being tested at the Mayo Clinic even allows you to reach a doctor, find a diagnosis, and track one’s medical records. The app, which is simply called “Better,” also includes Mayo’s online symptom checker.

Of course, a digital symptom checker is a two-edged sword. For a well-adjusted person without unrealistic fears of doom and destruction, it can help detect a serious health problem before it requires emergency care. For others, it’s one more excuse to worry about imaginary disease.

It’s so easy to fall into this trap when using a symptom finder because most diseases have no pathognomonic sign. In other words, there is no one signpost that definitively announces the presence of a specific disease. In their earlier stages, many life-threatening disorders announce themselves with vague signs and symptoms that can be caused by a hundred other minor disorders that usually disappear on their own. So it’s easy for a worrywart to jump to the conclusion that their persistent headache is proof that they have a brain tumor, when in fact it’s because they tried giving up caffeine cold turkey.

Mobile health, like telemedicine services, will eventually take us places we never dreamed possible a few short years ago. Let’s not waste time along the way measuring bodily functions that are better left unknown.

24 Oct 2013

Is your doctor spying on your tweets? Social media raises medical privacy questions

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Article by Art Caplan, Ph.D. NBC News, Oct. 21, 2013

A friend recently brought to my attention a disturbing question from a psychiatrist working with a transplant team: Should she be checking the sobriety claims of liver transplant candidates by looking on their Twitter and other social media sites? That question merits discussion because it’s clear both doctors and patients are entering a new world of uncertain medical privacy due to Twitter, Facebook, Google+ and other outlets.

In this case, the doctor was asked to offer an opinion about a young man’s eligibility for a liver transplant. The medical team would not take him if he was still drinking. The doctor knew the young man had a history of at least one binge-drinking episode more than a year ago that resulted in a car crash. Since then, both the would-be transplant candidate and his mother said he had been sober.

The psychiatrist was ready to recommend admission to the liver transplant program when she received a photo by email of the young man in a bar. Someone on the transplant team had thought to check the guy’s Twitter account. There he was for all the world to see, surrounded by booze, hoisting a cold one in a picture he himself had posted.

If you are still drinking you are not going to get into any liver transplant program. The picture was probably enough reason to turn away the young man —meaning in all likelihood a death sentence.

The situation raises vital questions about privacy and doctor-patient relationships that simply did not exist before the social media explosion.

Should this doctor or any health care professional have checked the transplant candidate out on social media? I can’t find any ethical guidelines that say no. But even if ethical restrictions existed, it is probably fair to assume that a lot of doctors and those who work with them, many who grew up with Facebook and Twitter and the like, will be tempted to do so.

How is that going to happen, you ask, when most doctors barely have time to see a patient much less spend hours hunting on the Internet? You have to remember now that anyone in the doctor’s office or out in the community can look at your social media profile and rat you out. And a lot of doctors make their living checking out the reliability of what patients say.

Take for example, you say your back really hurts and you are disabled — let’s take a peek at your Facebook page to see if you manage to hit the tennis court, the jogging path or the golf links. Promise to be abstinent due to your venereal disease—what are you doing on dating sites on Craigslist? Swear to stay away from fatty foods and high calorie treats—why did your doctor just read a review by you of barbecue joints on Yelp or Zagat?

Presuming doctors, their helpers or your neighbors are going to look, ethical standards or not, shouldn’t patients be told if someone does? I think so. I think the transplant candidate had the right to know that he tweeted himself right out of a shot at a liver transplant. And you need to realize that information you put up on social media sites may wind up being used by your doctor, hospital, psychologist, school nurse or drug counselor.

Right now there are no rules or even suggestions to guide doctor-patient relationships over the Internet. Both now have new ways to look at one another outside the office or exam room. If they are going to continue to trust one another then we need to recalculate existing notions of medical privacy and confidentiality to fit an Internet world where there is not much of either.

17 Oct 2013

States encounter ObamaCare impostors

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Article By Elise Viebeck, TheHill Blog, October 14, 2013

State insurance regulators are encountering sites designed to mimic ObamaCare’s enrollment portal, the online hub where millions of people are meant to purchase healthcare coverage. Attempts at imitating healthcare.gov have met with cease-and-desist letters; the sites could confuse consumers seeking to enter ObamaCare’s marketplaces.

In New Hampshire, the insurance commissioner reportedly cracked down on one webpage last week that could have been mistaken for the state’s insurance exchange.

And regulators from Washington, Pennsylvania and Connecticut are warning the health insurance industry against creating sites that might mislead the public.

The healthcare law is expected to prompt fraud attempts similar to those seen in Medicare and other government programs. It’s unclear whether the technical problems plaguing the ObamaCare enrollment portal are increasing the instance of consumer scams.

One classic trick is perpetrated when Medicare beneficiaries receive a call from someone who says they work from the government. The caller then asks for sensitive personal details — such as bank account and Social Security numbers — in the name of presenting the individual with a new Medicare card. Regulators fear that ObamaCare will give rise to similar scams and warn consumers not to release their personal information to unverified callers.

Top administration officials met in September to discuss the potential for abuse, though the government shutdown is inhibiting some anti-fraud actions. “We will be vigilant as always in cracking down on this type of opportunistic fraud,” Federal Trade Commission Chairwoman Edith Ramirez told CBS News.

10 Oct 2013

What everyone is getting wrong about Healthcare.gov

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October 7, 2013 Washington Post Article by Tom Lee

This Reuters article about Healthcare.gov has been getting some attention. Alas, it’s not very good, focusing on client-side optimizations that are probably unrelated to the federal health care Web site’s early woes. Healthcare.gov’s problems are almost certainly occurring at a deeper level in the system, making it very difficult, if not impossible, for an outsider to gauge how serious those problems are.

To explain, let’s do one of those analogy things. Say that Kathleen is planning a birthday party for herself.

There are a bunch of tasks associated with the party that need to be done. For instance, guests have to be told where and when the party is and whether to bring gifts. This is a pretty easy task to manage: Kathleen prints up a bunch of flyers with the relevant information and asks some friends to hand them out.

This task can be done well or poorly, of course. Maybe she foolishly printed bits of information on different pieces of paper instead of on a single flyer. Maybe she only asked one friend to hand them out and he’s a flake. These could become real issues if more people than Kathleen anticipated want to attend the party.

These are easy problems to solve, though. Printing more flyers is simple. You can hire people to hand out the flyers if your friends aren’t reliable. There’s no real need for these distributors to coordinate.

Some tasks require Kathleen herself, though. Receiving happy birthday wishes, for instance: There could be a huge number of guests, but there’s only one Kathleen. If she doesn’t plan for this properly, she could wind up being too busy receiving congratulations nonstop to enjoy the party. Perhaps her guests will have to waste their time queued up waiting for her, too.

Many Web application optimization problems can be categorized in a similar way. Some processes can be run in parallel, without central coordination. These processes might be implemented wastefully or unprofessionally, but you can usually fix them by throwing more resources at the problem. Cloud-hosting architectures often make this trivially easy.

Other problems require coordination or centralization. That can cause bottlenecks, and they can be quite severe. You can respond by rewriting, redesigning, tuning or, yes, throwing more resources at the affected systems. Sometimes this works and sometimes it doesn’t; it requires time and expertise, though, not just a credit card and an Amazon account. Sometimes your only real option is to design around these problems: Queue the expensive tasks for later execution, or accept a loss of synchronization across your system.

The Reuters article spends a lot of time on how many static resources are loaded into the browser by Healthcare.gov. Sometimes there are good reasons for loading a bunch of that stuff and sometimes there aren’t. The fact that there’s usually room for improvement — as any Web optimization tool will tell you — means that it’s pretty simple to make a critique of virtually any site. That doesn’t make the bugs and glitches critical problems, however.

Besides, the symptoms that usually show up with this class of problems are different than the ones afflicting Healthcare.gov. And many of the Healthcare.gov assets in question are served through the Akamai Content Delivery Network, which is probably the best-known brand name when it comes to making sure your servers can handle gigantic amounts of static asset requests.

It is much more likely that Healthcare.gov’s problems are related to the more expensive operations involving the insurance application process itself. Checking users’ eligibility and filing their applications requires integration with a separate and more complex set of systems — ones that have little to do with your Web browser. Fixing those sorts of jams can be easy or difficult; the boring truth is that it’s hard to say definitively from outside the system. Much harder than carping about uncompressed Javascript, at any rate.

Parts of Healthcare.gov are down right now, presumably under technical maintenance. Hopefully they improve the system throughput. Traffic is likely to even out after the initial crush of applicants, which should also help. Before long, I suspect that the site will work just fine.

It’s unfortunate that Healthcare.gov hasn’t made a great first impression. But it still has time to get things right. Once it does, there’ll be lessons to be drawn. But they’re probably not going to be ones you can generate automatically from a browser plugin.