Happy New Year 2014

Pushed by popular demand (translation - I think the one person who asked me is popular), I have drawn yet another in my series of poorly-drawn cartoons, in honor of the new year.  You can tell it's a new year-themed cartoon because it says, "HAPPY NEW YEAR!" right at the bottom.  It could have been a Halloween cartoon, I suppose, but I didn't draw it till now.  It is completely apolitical, unrelated to medical care, and has no social commentary at all.  Well, at least it really doesn't refer to electronic "health" records in any way.  Perhaps because, now that Mark is being employed by Epic, I have a conflict of interest.  Nah, just didn't happen.

I will try to blog more regularly.  There are lots of things I've been meaning to write about, so maybe I'll get off my rear at some point soon.

Anyway, to completely obviate the need for a brag letter that ain't coming, Mark is now working for Epic, proving that Zoology is a viable major, as long as you have a Computer Science minor, Keith is now a junior and it seems switching from Econ to Comp Sci (so he can get a Zoology job after graduation, I'm sure), and Rose had both knees replaced in July and is still not exactly a happy camper.

Best wishes to you (whoever you are, reading this) and yours for the new year!

And now, the alleged cartoon:

I am a really crappy blogger - nobody will come looking if I go 6+ months with no posts.  On the other hand, that could be considered an act of charity.  And, in the spirit of the season, a guest entry on charity from Ted Cruz:

Yes, Virginia, there is a Santa Claus

VIRGINIA, your little friends are wrong. They have been affected by the skepticism of a skeptical age. They do not believe even what they see. They think that nothing can be which is not comprehensible by their little minds. All minds, Virginia, whether they be men's or children's, are little. In this great universe of ours man is a mere insect, an ant, in his intellect, as compared with the boundless world about him, as measured by the intelligence capable of grasping the whole of truth and knowledge.

Yes, VIRGINIA, there is a Santa Claus. He exists as certainly as love and generosity and devotion exist – okay, even more certainly, since my actions and those of many of my colleagues and supporters raise reasonable doubt about the existence of love and generosity. Alas! how dreary would be the world if there were no Santa Claus. It would be as dreary as if there were no VIRGINIAS. There would be no childlike faith then, no poetry, no pretense that, despite its long history of failures to make tolerable this existence, the "free market" would solve all problems, including lack of access to health care by the uninsured indigent amongst us. We should have no enjoyment, except in the further accumulation of wealth by the 1%.

Not believe in Santa Claus! You might as well not believe in fairness! You might get your papa to hire men to watch in all the chimneys on Christmas Eve to catch Santa Claus, but even if they did not see Santa Claus coming down, what would that prove? Nobody sees Santa Claus, just as nobody has ever seen a free market in health care, but that is no sign that there is no Santa Claus. The most real things in the world are those that neither children nor men can see. Did you ever see fairness dancing on the lawn? Of course not, but that's no proof that it is not there – it could be, since it’s sure not in Congress. Nobody can conceive or imagine all the wonders there are unseen and unseeable in the world.

You may tear apart the baby's rattle and see what makes the noise inside, but there is a veil covering the unseen world which not the strongest man, nor even the united strength of all the strongest men that ever lived, could tear apart. Only faith, fancy, poetry, love, romance, can push aside that curtain and view and picture the supernal beauty and glory beyond. Is it all real? Ah, VIRGINIA, in all this world there is nothing else real and abiding. 

No Santa Claus! Thank God! he lives, and he lives forever. Otherwise, I should have to admit that the opposition of my colleagues, my backers, and myself to allowing all Americans access to some form of health insurance, however imperfect, was selfish, small-minded, wicked, and cruel, a phantasm produced by snorting the white pow(d)er of Koch – worse even than what Scrooge would abide.

Yes, VIRGINIA, there is a Santa Claus.  And he wants you to get off your lazy butt and get a high-paying job with good benefits, if you want more than a lump of coal this year.  Being 8 years old is no excuse for sloth.  To help you in this endeavor, we are also cutting off unemployment insurance payments to your parents, who would have gotten new jobs by now if they had not been narcotized by the government dole.

Yours truly,

The “Honorable” Ted Cruz

P.S.  Feel free to come by my office in Washington, DC any time for a cup of tea – but please bring your own tea bag.  Don’t be a moocher!

EHRs - evidence-free medicine?

I wasn't going to write another EHR-related post.  Not yet, time for a change.  But this article just came out online first in the Annals of Internal Medicine, funded by the Robert Wood Johnson Foundation and the Commonwealth Fund.  The conclusion of the abstract really says about as much as we all need to know, since we already all know it, except for ONCHIT, it seems:

Few physicians could meet meaningful use criteria in early 2012 and using computerized systems for the panel management tasks was difficult. Results support the growing evidence that using the basic data input capabilities of an EHR does not translate into the greater opportunity that these technologies promise.

And many large sites, like academic medical centers, have not just one, but several EHRs, along with perhaps a data repository or two, plus all the systems they have to interact with.  I guess the HITECH Act is good for the economy, guaranteeing that a bunch of people will have IT-support jobs that pay reasonably well into the indefinite future, and low risk of offshoring.

Or, to paraphrase the famous line from Treasure of the Sierra Madre (which I'd give more than 8.4/10 stars), "Clothes?  We don't have to show you no stinkin' clothes!"

I'll try for more variety in my next post.

A strong vote of confidence in our EHRs from current users

I just ran across a blurb today pointing to this article on the web discussing changes in EHR purchasing between 2010 and 2013.  I acknowledge that I have not done full due diligence to examine their methodology and biases, but I see no reason to believe that the figures they present are grossly distorted for any obvious reason.

Briefly, what caught my attention is that the proportion of those looking to buy an EHR in 2013 vs. 2010 who are replacing an existing EHR jumped from 21% to 31% (but this article suggests it could be as "low" as 17% in 2013).  My first thought was that maybe these were people changing from discontinued/unsupported systems; this is why a couple of community health centers I know of here in Massachusetts made that move, because they had MISYS and AllScripts bought and shot it.  However, a bit farther down, data are shown that by far the largest reason for switching was dissatisfaction with the old system and this was more common in 2013 than 2010, with >60% citing this as their reason for switching in 2013.  Given the issue of EHR lock - the systems are very expensive and vendors make it as hard as possible to get your data out to move to another EHR (generally not even providing users a data dictionary to understand how their own patient data are stored) - jumping ship to another EHR because of dissatisfaction means you really hate the one you have.  Then think about all the costs of retraining clinical and support staff for the new EHR, the lost productivity as they go through another learning curve - the costs are likely not much lower than buying an initial system, though I've never seen any articles with data about the costs of switching.  You truly have to hate your EHR to switch because you don't like it rather than because it is no longer supported or doesn't qualify for Meaningless Use incentives.  (And let's not even think about the poor schmoes who bought an "EHRMagic" EHR and learned that the magic was that their MU certification would disappear.)

Strong incentives to buy black box products with penalties coming soon for not using them (e.g., not using e-prescribing), when there are huge exit barriers, bears no resemblance to the assumptions of a "free market."  I really wish that the "anti-big government" forces in Congress would go after this one.  Unfortunately, as we all know, they are quite happy with a forced subsidy to big business, even at the price of more expensive, lower quality health care and worse health for Americans.  But nobody gets elected, or voted out of office, on the basis of their positions and votes related to EHRs, do they?

And I can think of no better way to end this rant than with a turkey photo or two.

More EHR crankiness - parallel evolution or just unacknowledged copying?

I just bumped into this letter submitted as commentary to Congress from the "Healthcare Innovation Council" of Antheliohealth.  The members are certainly more prominent than I, and while Antheliohealth is clearly in the business and hence potentially biased, they make very similar comments to those I made in the Health Affairs Blog post I linked to in my previous posting here.  It is interesting that they used virtually the same title as I did (though I could not believe I somehow sent mine in as "The EHR Has No Clothes" and not "The EMR Has No Clothes"), without any attribution and, more importantly, without sending me a large check.  But it could just be parallel evolution.

They went all the way to suggesting an end to the "Meaningful Use" program (I believe that is referred to in the trade as an act of MUtiny).  I had wanted to do that in my HA Blog piece but figured that would make it truly unpublishable - and it was already an incredible thrash to finally get it published anywhere.  And there is the issue of fairness - those adopting EHRs now are counting on the MU payments to help them cover the frequently obscene costs.  Even I think that abruptly ending the program would be unfair and unwise.  But there are, er, fair and balanced options that could be chosen.  E.g., the MU Stage 2 rollout could be put on hold while the specifications could be revised to focus on truly meaningful use - helping providers deliver higher quality, more patient-centered care.  One could even put a freeze on eligibility for MU incentives - e.g., no contracts for an EHR by an organization not already using a certified EHR signed after a specified date would be eligible for MU payments until the freeze was lifted when the new MU Stage 2 requirements were issued.

And I still don't understand the incredible resistance to adopting VistA.  Sure, it needs installation and support, but all EHRs do, and the software licensing cost is $0, which leaves a lot of money on the table for installation and support.  (I've offered to cover the entire software acquisition cost for my clinic if we dump NoxGen for VistA.)  It actually has evidence for improving care and, for an enterprise-level EHR, is relatively well-liked.

But, I know, I know, it has no glitzy GUI and is written in that truly archaic language, MUMPS.  As is Epic...

Ok, for you non-geeks who accidentally clicked on this, here's a picture of a white-breasted nuthatch in our backyard for your troubles (those are maple flowers in the tree):

Your HIT parade - Problem lists!

As some know, I think our national electronic health record (EHR) policy is woefully misguided - providers/organizations are being pushed hard to buy an EHR, any EHR (I think the official title of this strategy is, "Let 1,000 EHRs fester"), with the costs of acquisition and barriers to exit so high that most purchasers get locked into whatever they buy, even after discovering it is a POS and most of what they were promised was vaporware.  These complex systems are devoted to charge capture/justification, not patient care, and are chief suspects in increases in Medicare coding intensity/costs unrelated to any actual changes in care. (Here's the NY Times article.)  Well, duh!  They are NOT, in general, focused on helping clinicians actually provide better care (except for the few that were actually developed by clinicians to help them practice).  However, I can think of few ways to make this clearer than the email I received today:

Health Resources and Services Administration

Health Information Technology and Quality Improvement Webinar

Friday, May 17, 2:00 PM ET

“Using an Electronic Health Record to Create Patient Problem Lists”

This webinar will focus on how safety net primary care providers can meaningfully use electronic health records (EHR) to create and maintain patient problem lists.  Created by EHRs, patient problem lists are a core requirement of Meaningful Use. This function serves as a powerful tool for maintaining a patient’s medical history while also helping to engage patients to better track and manage their health care.  

Presenters will demonstrate how patient problem lists are created and maintained by EHRs, and share their strategies on how providers can use them for quality improvement and patient engagement.  Lastly, staff from the U.S. Department of Health and Human Services will discuss the importance of patient problem lists in achieving Stage 1 and 2 of Meaningful Use.

Register here: https://cc.readytalk.com/cc/s/registrations/new?cid=3g2cm558x3gp.

Previous HRSA Health IT and Quality Webinars can be accessed at the HRSA Health IT and Quality Webinar website: http://www.hrsa.gov/healthit/toolbox/webinars/.

Questions for presenters are welcome prior to the event and may be emailed to healthit@hrsa.gov.

If a webinar is needed to help people learn about creating problem lists in their EHRs and discuss how they can be useful in patient care, we are in seriously deep trouble.  After being sure you are looking at the right chart, the problem list is typically the first thing you look at.  How can it be possible that we are pushing people to buy and use such useless crap where conducting such a webinar does not seem utterly nonsensical?  And that people are paying many thousands, and often millions, of dollars for these pieces of crap.

Don't get me wrong - as a geek, I think the EHR has huge potential for increasing the efficiency and effectiveness of health care.  I just think we are squandering nearly all of that potential with our current, misguided policies and driving costs up substantially with little or no payoff.  Except to the EHR companies, who are making billions.  "Free market" Republicans should be up in arms over this forced subsidy - except, of course, they really care about helping businesses make money, not free markets, competition, efficiency, or saving taxpayer money.

Stay tuned - I hear that next year, HRSA and ONCHIT are planning on cosponsoring an advanced-level webinar, "Creating a Progress Note Using an Electronic Health Record." 

The Guns of Never One (with apologies to Alistair MacLean)

This will probably be my last posting on guns for a while.  I hope...

I love hearing gun nuts (and specifically the NRA) argue that the problem with gun violence is not related to high prevalence, unsafe storage, lack of background checks for gun show and internet sales, etc., but an issue of keeping “mentally ill” people from obtaining guns.  While fighting vigorously against any national registry of gun ownership, he advocates for creation of “an active national database of the mentally ill”.  For some reason, alas, he has neglected to publish the criteria that would constitute the admission ticket to this elect group, nor does he seem to contemplate several other issues:

1. Isn’t creating a national registry of the “mentally ill” a far greater intrusion on liberty and the right to privacy than a registry of gun owners?  The latter is a voluntary choice.
2. Since mental illnesses are defined and redefined essentially by consensus, inclusion on such a list has a substantial degree of arbitrariness, both in condition definition and assessment.  Furthermore, since symptoms wax and wane, many people cross back and forth across the magic lines we draw for diagnosis on a regular basis.
3. We have very poor predictive ability for homicide and suicide among persons with serious medical disorders (see, for example, this article).
4. Many people who commit violence with guns would not meet criteria for any list of diagnoses that the NRA and its allies would agree to.
5. In contrast, felons have already been convicted of criminal behavior.

In my practice in community health centers and public hospitals, I have had patients who have been victims of gun violence and patients whose families have been affected by gun violence.  A couple of years ago, I was told that one of my patients had died.  He certainly had mental illness, and was seeing a counselor and taking medications.  He had grown up as a victim of violence and had a violent youth.  He was struggling to keep his life together and, especially, to keep his teenage son from following in his footsteps.  But, as it turns out, he had an estranged ex-girlfriend I had never heard about who had a no-contact order on him.  One day, he found her in a store, shot and killed her, went back to his room, and committed suicide.  Would I have wanted him to have a gun?  No.  Would I have expected him to use a gun on someone?  No.

If the NRA trusts the nation’s medical providers to make the determination of who can safely be allowed to own a firearm, practitioners of evidence-based medicine can help:

1. As above, we have no good way of predicting who will commit a gun-related crime or suicide.
2. However, owning a firearm, or having one in the house, substantially increases the risk of gun-related suicide, homicide, and injury.

The answer seems pretty obvious.  In fact, I am willing to take on the burden of being “The Decider” for the entire nation. 

Q:  Should _____ (fill in name) be allowed to own a gun?

A:  No.

Repeat as necessary.

(P.S.  In fact, I am perfectly happy to allow responsible ownership, storage, and use of hunting rifles; in Alaska, for example, many people really are subsistence hunters, and we have to do something to control deer populations with their natural predators eliminated.  But do we need more 5 year olds being given "first shotguns" and then killing 2 year olds???)

What, Exactly, Is It that We Don’t Understand about the Right to Bear Arms?

            Americans continue to face a civil rights crisis.  Following the recent, tragic events in Boston, Wayne SelPierre, Executive Vice President of the National Bomb Association, stated, “The only thing that stops a bad guy with a bomb is a good guy with a bomb.  As long as bombs are illegal, only criminals will have bombs.  And we have seen that outlawing bombs has not kept them out of the hands of criminals, while law-abiding Americans have been deprived of their Second Amendment rights by monumental, unconstitutional overreach by the federal government.  The NBA believes it is time that Americans have their constitutional rights to bear any and all arms restored and we will be filing suit against the federal government challenging the unconstitutional infringement of our right to bear bombs.”

            Pundits in the lamestream media have claimed that the NBA is a bunch of extremist nut cases, but if the Founding Fathers had only intended for Americans to have the right to bear firearms, they would have said so.  “Arms” is a synonym for armaments and a quick check in any dictionary makes it clear this is not limited to pistols, rifles and assault weapons.

            Some might argue that bombs have no uses other than to kill and maim, but these unenlightened persons have obviously never engaged in the sport of dynamite fishing, nor used a small explosive charge to open the lid on a too-tightly closed jar of pickles.  Bear bombing is a far more challenging sport than bear hunting with a rifle.  It requires both getting much closer to a bear than needed with a barely-sporting hunting rifle with telescopic sight and anticipating speed and direction changes a bear will make while lobbing your grenade.  A child who has learned to throw the grenade not where the bear is, but where the bear will be, is a child who has learned an invaluable life lesson.  She will be a leg up on her non-bear bombing peers, assuming no hunting accidents.  Cleaning and cooking a detonated bear similarly requires far more skill and effort than slicing up and roasting an intact carcass.

            Some might argue that the Founding Fathers could never have anticipated modern developments in personal explosives like dynamite, plastic explosives, and IEDs, but that’s the same, lame argument that the Senate rightfully discarded when courageously refusing to buckle to the will of the majority of the American people and ban assault weapons or magazines holding large numbers of bullets.  In fact, the inability of the Founding Fathers to anticipate those advances in personal firearm technology is what makes regaining the right to personal explosives so crucially important.  While Wayne LaPierre of the NRA claimed that the only thing that can stop a bad guy with a gun is a good guy with a gun, the NBA has pointed out that, against a gunman armed with multiple assault weapons with high capacity magazines and wearing body armor, an individual with a concealed pistol has virtually no chance – but a patriotic American lobbing a concealed grenade at the gunman or gunwoman?  Game over.

            When even a Canadian peacenik like Bruce Cockburn wistfully sings, “If I Had a Rocket Launcher,” it is clear that this un-American, unconstitutional restriction on our right to bear arms must go.  I hope that our courageous Congress sees fit to act without waiting for the NBA case to proceed glacially through the court system so that, eventually, the Roberts court can restore our constitutional rights.

            It is important not to lose sight of principle and just grab an easy, incomplete victory.  The Second Amendment gives Americans the right to bear arms.  Period.  Next week, I’ll discuss handy, home uses of sarin wrap.

Owner-Donor: Two Words to Make Guns Life-Saving

            Let’s get real – people with guns and ammunition kill people.  There is overwhelming evidence that restrictions on access to semiautomatic weapons, high-capacity magazines, and just plain guns reduce gun-related deaths – not just murders but suicides and accidental deaths.  Despite that, it seems unlikely Congress is going to do anything that could actually make Americans safer and reduce the carnage.  But does this mean we should throw in the towel?  Absolutely not – a towel thrown in the air could easily be mistaken for a skeet, with very unpleasant consequences.  Yelling “Duck!” when throwing the towel would only increase the risk.

            Instead, we need accept that our elected representatives lack the guts to stand up to the gun lobby and move on to more constructive ways of dealing with the mayhem we know will continue coming.  First, there is an obvious way to make guns save at least as many lives as they take.  No, I don’t mean requiring every man, woman, and child to pack heat.  More guns = more death, remember?  Rather, without restricting access to guns at all, we simply pass a law that requires anyone owning a gun to agree to be an organ donor – the Owner-Donor law.  Sure, you say, but what about those cases where the gun owner has not committed suicide or been shot with his or her own gun, hopefully sparing the heart, lungs, kidneys, liver, and other transplantable organs?  No problem – living organ donation is already accepted and widespread.  If you shoot someone with your gun and it is not found to have been self-defense against a legitimate mortal threat, you have just agreed to donate a kidney and/or a lobe of your liver.  You can keep your other kidney – unless you do it again.  If your gun is not securely stored and is used by another person to harm someone, you have also just agreed to become a donor – thank you.  Use of a gun in committing a crime, similarly, should constitute an automatic donation consent, so if your stolen gun is used to commit a crime, thank you twice! 

            Imagine the headlines this policy could create.  “RISE IN GUN DEATHS OVERWHELMS HOSPITALS WITH ORGAN TRANSPLANTS – ORGAN WAITING LISTS ELIMINATED!”

            Of course, some might criticize this as a facile oversimplification that ignores the real complexities involved.  Adult-sized organs are not suitable for transplantation into children, so how could this proposal address the needs of children awaiting organ transplants?  But I am not the only person to offer facile oversimplifications in the debate about gun violence.  Wayne LaPierre of the National Rifle Association made the absurd statement after Newtown that the only thing that can stop a bad guy with a gun is a good guy with a gun.  But that strategy did not stop Columbine.  Besides, what if the good guy has a bad day?  Do we need two armed good guys, keeping eyes on each other all the time?  And then how will they see the armed bad guy approaching?

            Instead, we need to mandate that all schoolchildren pack heat in school.  Given the importance of guns in American society, it is criminal that we are not devoting at least 25% of time in school to guns.  If recess were changed to target practice and physical education (or science – gun advocates don’t seem to have much use for that) to firearm education, we could finally lead the world in one area of education and guarantee that any bad guy thinking of going into a school for target practice would think at least twice.  Which would be at least two times more than many gun advocates seem to be thinking.

            But, you say, kids tend to have poor impulse control and not think through the long-term consequences of their behaviors.  If Sally dumps Harry’s lunch tray, isn’t there a risk that Harry will draw and somebody, or some bodies, get shot?  Sure, but it’s a small price to pay for liberty.  Besides, did you forget about all the kids on the organ transplant waiting list?  With Owner-Donor, when Harry shot Sally could yield 2 kidneys from the late Sally, 1 from Harry, another from Harry’s mom or dad who was the registered owner, plus Sally’s other useful organs.

            As the famous American philosopher Benjamin Parker once said to his nephew, “With great power, comes great responsibility.”  It is time for American gun owners to step up to the plate – and the operating room gurney.

A blog? What's up with that???

I have gotten frustrated that many pieces I write, whether "humor" or policy-related, keep not getting published.  There's not much point in writing just for yourself.  Several friends have suggested starting a blog (soooo last decade, I know, but I remain firmly committed to antisocial networking - no Twits, Tweets, Facebook, etc.).  I suspect they are just hoping not to keep getting crap in their inboxes that they need to delete immediately but occasionally start reading before realizing their mistake.  Far easier to ignore a blog or an email saying "Read my latest blog posting.  Please???"

I will start off with a couple of satiric pieces I wrote on the topic of gun control and have not been able to find a venue willing to accept.  After that, all bets are off.  You may see health policy musings, rants about our stupidity in health information technology policy, poorly-drawn cartoons, pictures of animals or plants I've taken (but NO cute kitty pictures, I promise!  I reserve the right to put up cute puppy pictures, should we ever get a dog.  I.e., don't worry about that, either), or just about anything else.

Feel free to pass the site on to friends you want to lose, strangers on the street, eccentric billionaires or publishing magnates you know, or anyone else.  After all, Google will tell me if nobody is ever reading this, which could push me back to email inundation for dissemination.

Just to prove that entropy always wins, below are a few recent, random photos.  The first is just a demonstration of what kind of pinko I am.

Yes, those are emerging fronds of a bleeding heart.

An emerging fern frond.  I just think they look very cool.  And, after New England winters, I cannot be happy enough when spring gets here.

Developing maple seeds - I am amazed at how colorful they are.

A white-throated sparrow in a blooming forsythia bush in the yard.