While it works on a cellular level, one wonders what it might do to a real heart...Bzzzaaaaaapppppp....
-Wes
Image reference.
Friday, May 30, 2008
A Lab-Based Optical Pacemaker
While it works on a cellular level, one wonders what it might do to a real heart...Bzzzaaaaaapppppp....
-Wes
Image reference.
Thursday, May 29, 2008
The Astrophysics of Surgery
When the moon is in the Seventh House
And Jupiter aligns with Mars
Then peace will guide the planets
And love will steer the stars.
-"Age of Aquarius," by the 5th Dimension
Scheduling surgery can be tricky:
"I'm sorry, doctor, I can't get my pacemaker then."
"Why not?"
"Mars is in retrograde."
-Wes
Wednesday, May 28, 2008
The First Real Hospital Quality Measure
How many hospital measures exist for physicians today? Answer "119." (Somehow I count 134, but hey, what's the difference)
Now, how many hospital measures exist for hospitals today? Answer: 35.
But these quality measures for hospitals, are really clinical measures for physicians, so all told, physicians now have 155 quality measures to which they must conform, should they want to be paid.
The bottom line is that hospital quality measures, as they exist today, are really more physician quality measures.
But hospitalists are paid by hospitals, and as such, have now become a "hospital quality standard." Same with nocturnists - hospitalists that do the night shift. Heck, these used to be medical students and residents, but because of the ever-growing concern over sleep deprivation in medicine, residents' hours may soon be restricted to 56 hours a week. With the growing realization of the paucity of care delivery after hours, coupled with the reality of the need for 24/7 care, hospitals are now in the position to differentiate themselves with a measure that can actually affect outcomes.
So, here's my proposal for the first real hospital quality measure (always looking for ways to cut the bureaucracy):
Does the hospital employ full time hospitalist and nocturnist services?
The next might be clinical nursing staff to patient census ratios.
Once we stop confusing hospital quality measures with physician quality measures, we might get somewhere.
-Wes
Now, how many hospital measures exist for hospitals today? Answer: 35.
But these quality measures for hospitals, are really clinical measures for physicians, so all told, physicians now have 155 quality measures to which they must conform, should they want to be paid.
The bottom line is that hospital quality measures, as they exist today, are really more physician quality measures.
But hospitalists are paid by hospitals, and as such, have now become a "hospital quality standard." Same with nocturnists - hospitalists that do the night shift. Heck, these used to be medical students and residents, but because of the ever-growing concern over sleep deprivation in medicine, residents' hours may soon be restricted to 56 hours a week. With the growing realization of the paucity of care delivery after hours, coupled with the reality of the need for 24/7 care, hospitals are now in the position to differentiate themselves with a measure that can actually affect outcomes.
So, here's my proposal for the first real hospital quality measure (always looking for ways to cut the bureaucracy):
Does the hospital employ full time hospitalist and nocturnist services?
The next might be clinical nursing staff to patient census ratios.
Once we stop confusing hospital quality measures with physician quality measures, we might get somewhere.
-Wes
Tuesday, May 27, 2008
EKG Du Jour - # 8: The Case of Abdominal Pain
A 77 year old woman with a long-standing history of Crohn's colitis presents to the ER for left lower quadrant abdominal discomfort, nausea, and loose stools for a week. She denied fever, chills, syncope, lightheadedness, palpitations, or chest discomfort, but did have a "fall" three days prior to admission at home whose circumstances were unclear to her. She has a long-standing history of coronary artery disease with preserved left ventricular function and atrial fibrillation. She received an AV nodal ablation and dual-chamber permanent pacemaker implantation in 2001. She had not made her last two pacemaker clinic follow-ups "because I just felt too bad to go."
Her medications, which were not changed, included metoprolol 50 mg daily, Lasix 40 mg daily, and warfarin.
Examination demonstrated normal vital signs with the exception of an irregular pulse, and a cardiovacular examination with a fixed split second heart sound. Her abdomen demonstrated a slightly tender left lower quadrant without rebound, normal WBC count, and her stools did not contain blood.
Here's her EKG:
She was seen by the GI service, who felt her history and examination was most consistent with a Crohn's disease flair and began her on a Prenisone taper (40 mg daily for three days and tapering over 2 weeks until off).
Her internist wasn't sure about the EKG and asks you to evaluate her.
What do you tell him? Plan?
-Wes
Her medications, which were not changed, included metoprolol 50 mg daily, Lasix 40 mg daily, and warfarin.
Examination demonstrated normal vital signs with the exception of an irregular pulse, and a cardiovacular examination with a fixed split second heart sound. Her abdomen demonstrated a slightly tender left lower quadrant without rebound, normal WBC count, and her stools did not contain blood.
Here's her EKG:
Click image to enlarge
She was seen by the GI service, who felt her history and examination was most consistent with a Crohn's disease flair and began her on a Prenisone taper (40 mg daily for three days and tapering over 2 weeks until off).
Her internist wasn't sure about the EKG and asks you to evaluate her.
What do you tell him? Plan?
-Wes
Monday, May 26, 2008
Happy Memorial Day
As we gather with friends and family to cook the bratwurst, hamburgers, chicken or ribs and taste the cole slaw or potato salad washed down by a refreshing frosty one, take a moment to click on a name and remember what others have sacrificed for our freedom and way of life.*-Wes
*Warning: Kleenex alert. I couldn't take it after viewing a couple of these. God Bless America.
Image reference.
Sunday, May 25, 2008
What Doctors Do at National Meetings
Here's a cool time-lapse movie of the comings and goings at the ACC in New Orleans in 2007:
Kind of reminds me of Brownian motion in the physics lab.
-Wes
Kind of reminds me of Brownian motion in the physics lab.
-Wes
Saturday, May 24, 2008
The Dog and His Master
Good dog. Sit. Siiittt.
Now, I see you use claims-based reporting to Medicare.
Gooooooddddd.
Just fill out three or more measures of 80% of your "applicable" patients OR one measure for 30 consecutive patients OR one measure for 80% of your "applicable" patients for the entire year.
Adda boy!
Now fetch that paperwork. Fill it out.
That's my dog!
Now, check the calendar. Still before 1 July?
Goooood. You can qualify for the whole biscuit still! Whew!
And did you see, CMS has increased the number of "measures" from 74 to 119 just to make it easier for you, boy!
Sit! Now sssiiiiiittttt. Don't try to get up boy. Don't do runnin' off after that ol' 'coon boy. That's it. That's a good internal medicine dog. Don't you see boy? You make about $200,000 a year, and if you behave and do those tricks, I'll give you that biscuit we've been talkin' about. But you gotta behave, boy! Do what I tell you.
Yep, I got you that Special $3-K biscuit!
Oooop. Stay boy! Why you runnin' off? Damn it boy! Stay! How many times I gotta tell you? You don't mind your manners, and we're gonna put you back in your cage, dammit!
What's that? Why you growlin' boy? We're just tuggin' your leash a little. Oh I know, I know, you see 70 patients a week for 40 weeks a year. You know, it's a about a buck a patient... Come on, boy! That's it, boy. Fill out that paper work! Document it! Document that you documented it.
Gooooddd. What a good quality-based purchasing dog!
Ooop, I see you missed one of your 30-in-row patients, boy. Sorry, no biscuit for that one. Maybe you'll hit the 80% mark of all your other patients with that measure.
What's that, boy? Not sure which one your measurin'? Oh now, now, don't worry. Just measure, boy. See the biscuit? Yep, I still have it! Adda boy, keep workin', boy!
What a good dog!
What the...??? Where the hell you goin', boy? Get back here! Get BACK here! DAMN IT! I work my butt off to train these damn dogs and they up an bolt to the hospitals. Every frickin' time.
Oh, well. He'll come back. Hunger and our hospital rankin's have a way of doin' that.
-Wes
Now, I see you use claims-based reporting to Medicare.
Gooooooddddd.
Just fill out three or more measures of 80% of your "applicable" patients OR one measure for 30 consecutive patients OR one measure for 80% of your "applicable" patients for the entire year.
Adda boy!
Now fetch that paperwork. Fill it out.
That's my dog!
Now, check the calendar. Still before 1 July?
Goooood. You can qualify for the whole biscuit still! Whew!
And did you see, CMS has increased the number of "measures" from 74 to 119 just to make it easier for you, boy!
Sit! Now sssiiiiiittttt. Don't try to get up boy. Don't do runnin' off after that ol' 'coon boy. That's it. That's a good internal medicine dog. Don't you see boy? You make about $200,000 a year, and if you behave and do those tricks, I'll give you that biscuit we've been talkin' about. But you gotta behave, boy! Do what I tell you.
Yep, I got you that Special $3-K biscuit!
Oooop. Stay boy! Why you runnin' off? Damn it boy! Stay! How many times I gotta tell you? You don't mind your manners, and we're gonna put you back in your cage, dammit!
What's that? Why you growlin' boy? We're just tuggin' your leash a little. Oh I know, I know, you see 70 patients a week for 40 weeks a year. You know, it's a about a buck a patient... Come on, boy! That's it, boy. Fill out that paper work! Document it! Document that you documented it.
Gooooddd. What a good quality-based purchasing dog!
Ooop, I see you missed one of your 30-in-row patients, boy. Sorry, no biscuit for that one. Maybe you'll hit the 80% mark of all your other patients with that measure.
What's that, boy? Not sure which one your measurin'? Oh now, now, don't worry. Just measure, boy. See the biscuit? Yep, I still have it! Adda boy, keep workin', boy!
What a good dog!
What the...??? Where the hell you goin', boy? Get back here! Get BACK here! DAMN IT! I work my butt off to train these damn dogs and they up an bolt to the hospitals. Every frickin' time.
Oh, well. He'll come back. Hunger and our hospital rankin's have a way of doin' that.
-Wes
More Fun at MedTees
I just finished putting a few new suggested designs that passed our "highly selective" peer-review process on MedTees.
One is for ladies with celiac disease, shown here:
But my new favorite might be this for post-hysterectomy patients:
What do you think? Got another one?
-Wes
One is for ladies with celiac disease, shown here:
But my new favorite might be this for post-hysterectomy patients:
What do you think? Got another one?
-Wes
Friday, May 23, 2008
The $1.9 Million Shout-Out
Yep, the cost of a one-day ad campaign by the Centers for Medicaid and Medicare Services to promote their hospital rankings:
-Wes
Officials there are spending $1.9 million for a one-day advertising blitz in 58 local markets, including Chicago, urging consumers to compare the quality of care at medical institutions.I wonder why they have to advertise? Aren't people using these rankings? I mean, they're so helpful and save money, no?
-Wes
Thursday, May 22, 2008
Saying Goodbye to High School
Well done, buddy.
-Wes
Addendum: 23 May 2008 @ 1505 CST: Wow, this just in. No wonder I felt better today...
Today's Healthcare: The Davids vs the Goliaths
This is a first in a series of "point-counterpoint" debates between myself and Pete and Matt over at MarketIntellNow - a blog devoted to the promotion of e-health, the Electronic Medical Record, and the Patient Medical Record. Our topics will revolve around three areas:
1. Consumer-Driven Healthcare-- crock or crusade?
2. Doctor and hospital ratings-- fad or phenomenon?
3. John & Jane Doe-- patients or consumers?
I'm starting, then they'll counter, then I get a rebuttal, and so forth. Hopefully, it'll be entertaining and informative. Feel free to join in and make your thoughts known (I don't mind being handed my fanny once in a while.)
Unfortunately, I have to go first, so here goes...
* * *
Pete and Matt are right. E-health is all about the patient. Really it is.
After all, the Goliaths of Business tell us so.
You know them: Google, Microsoft, Walmart, Walgreens, IBM, Aetna, UnitedHealth, MedCo, Blue Cross, Quest Diagnostics and many, many many others. All told, as of 20 May 2008, the valuation of these companies alone exceeds $953 billion (yes, that’s right, nearly one trillion) dollars: a sum that is half the entire domestic product of all of China and a formidable sum to even begin to comprehend.
You the Consumer
With that purchasing power, we are now only too happy to hear that they are all about health, too. No doubt some of this corporate response is driven by the need to simplify an abysmally complex healthcare delivery system and Byzantine medical billing systems. But just as probably because the nation’s healthcare tab exceeds $2.3 trillion dollars and represents a rich cornucopia of new revenue streams. So, like knights with really shiny armor, each is ready to swoop down to rescue the healthcare system and its "consumers" with nothing but pure beneficence as their goal. Yes, dear patients, they’re all about you, the "consumer" and your "wellness."
After all, you are entitled to any healthcare you want. You deserve the best, the newest, the shiniest, the most plush accommodations. Anytime, anywhere, 24/7. You, dear consumer, can have it all. Oh, it might cost you a bit, sure. But our ever-friendly insurers are here to help with that. Just please, keep “consuming,” for when you consume healthcare services, you feed the beast that feeds our new economy. Our business partners will be sure to provide the information about your choices for hospitals and doctors and testing facilities for “screenings” and “prevention” right at your fingertips. And because they know that each state has different rules and different insurance policies, they’ll even allow you to filter the choices by where you live!
But that’s not all. Many will also provide you with the “best” hospitals and rehab facilities for your care, complete with rankings, too. No doubt they’ll steer you to the plan that suits you and your budget, dear consumer, the best. Have fun choosing. (Just be sure to make the right choice, will you, lest you be stuck paying a $105,000 cover charge for your cancer treatment.)
So they make websites. Quite expensive websites. Unfortunately, these websites might not save costs to our healthcare system, but heck, who cares? It's all about you, the healthcare consumer computer-surfer, remember? After all, they won't be built with the Goliath's money, mind you, but yours. Personal Health Records and informational sites. Tons and tons of them. Some better organized than others – some with pleasing color schemes and most with lots of smiling faces. And each of these sites will promise to house healthcare needs (and portions of your medical record) under one roof, provided you give your “permission.” For some, you can even grant other pharmacy, laboratory and hospital services to upload your medication, laboratory, and procedural information, too – all neatly organized. What's not to like?
But God help you if you make a typographical error or your name is a common one like John Smith (he'll need his Social Security Number and date of birth to differentiate himself from the other John Smiths out there – while providing yet another exposure for identity theft – but, hey, the information will just be used for healthcare – and maybe a bit of advertising). You see, unique identifiers are a challenge to healthcare databases. It’s tough to know you’ve got the right “John Smith” when databases are shared. The wrong “merge” and voila, you got a whole new set of preexisting conditions that the insurers can use to crank your premiums. Who will help rectify the situation? What about the other “John Smith’s” privacy? Oops.
Rankings Schmankings
True, Personal Health Records and informational websites can have answers to your questions. They have forums. They have information on your doctors and hospitals – like credentials and rankings. But these rankings are created by many, many sources: the government, marketing firms, and advertisers. Each of these ranking systems have significant limitations and use criteria that are non-uniform and only intermittently updated and almost never verified. (That, my friends, would take innumerable man-hours to maintain.) But they all claim they are the best at helping you choose your doctor or hospital with no proof as to their effectiveness. * Sigh *
Now is there a ranking that identifies the quality doctors based on the time they take with you, or if they answer your questions, or act as your advocate or evaluates your actual treatment outcomes? No. Instead, we are told that "quality doctors" are the ones that give aspirin 100% of the time after a heart attack, or prescribe beta blockers for heart failure. THAT, my friends, is just two of the ever-expanding 119 major measures that we should strive for! And these same rankings are often used for marketing of healthcare facilities. Heck, some hospitals with carefully collected quality assurance measures even pay to have their doctors “ranked” since their data always looks so good! All to help you, dear consumer, to make the right choice. After all, it is much easier (and politically correct) to implement e-health initiatives that hire more bureaucrats than to simplify the bureaucracy and redundancy by cutting unnecessary jobs!
Oh, and yes, they own all of the data. Your healthcare data.
That’s right, not you. Them.
And the Goliaths carry nary a liability concern regarding its accuracy – you saw that disclaimer, didn’t you? And don't forget, all of this data is no longer officially protected by the Health Insurance Portability and Accountability Act. Bits and bytes galore, all whirring this way and that for any number of eyes to see. All without any recourse or tracking capability and all at the speed of light. Because you, my friend, have authorized "sharing." But that’s not all. On some sights you’ll be targeted with advertisements to "empower" your healthcare choices. For many companies, this is the business model for their survival. So just how “secure” is your healthcare information if keywords you’ve entered are triggering the ads placed on your webpage? And although the Goliaths want to compare the security of banking transactions to healthcare transactions, are not the issues of identity theft real for both types of transactions? Correcting your widely disseminated “personal record” after it's been compromised is nearly impossible once the imprint of a preexisting conditions exists on your record. Good luck contacting Google to straighten that out.
The Goliaths, my friends, may soon become the Great and Powerful Oz of Healthcare, conveniently hiding their liability (and profit motives) behind a great electronic curtain called the Internet.
The PMR is not the EMR
But we mustn’t be too harsh. There are really good aspects to the personal health record and informational websites. Where else is there universal ability to transport your healthcare information between disparate institutions? Where else can you get a relatively unbiased search of information? Where else can you empower yourself with an avalanche of mostly reliable information and share experiences with total strangers who may have endured your same ordeal. But we mustn’t confuse the Personal Health Record, editable by all, as an Electronic Medical Record (EMR). The EMR contains the official transcript of your healthcare received. The EMR is the ultimate arbiter of healthcare delivery that is the undisputed king of records used in liability proceedings. As such, there is little incentive for physicians to maintain two sets of records. The Personal Health Record is just that: personal. It is NOT a health record. Sorry.
And if you want to have a Personal Health Record, you’d better not be too sick. If you can’t type or see, Personal Health Records and computer-driven healthcare might not be in your best interest, but there certainly might be a place for a caregiver to follow your healthcare delivery. Personal health sites leave a huge gap for services since they assume all "patient-consumers" use or have access to computers and will shop for “healthcare” like the latest dress or are physically and emotionally capable to use the sites as intended.
And what does this Goliathian healthcare look like on the ground? I'm just not sure yet. One only needs to look at the recent unfortunate recent circumstances of Senator Ted Kennedy to begin to comprehend the issues.
Imagine. Senator Kennedy comes into the ER with confusion, obtundation, and maybe not moving his right side very well. Did the doctors rush to Google and type in his symptoms? Oh, they could have. And they would have been met with a differential diagnosis of 870 different entries with AIDS, Creutzfeldt-Jakob disease, and inflammatory disease of the brain as the first three results after only 0.35-0.48 seconds. Hardly an accurate assessment, as we’ve seen.
And what about those hospital rankings to choose a hospital? Did the Kennedy's have a choice where he went first? Not really. He was appropriately taken to the closest facility. But more importantly as WhiteCoat has already pointed out, the family opted not to stay at that “Top 100” hospital, but rather elected to transfer him to an unranked hospital: Massachusetts General Hospital. So given all the different ranking systems out there, which ranking mechanism will you, dear “consumer,” use to make your choice of healthcare facility? Could it be that these marketing gimmicks called “rankings” might not have your best interests in mind?
And how about his diagnosis? Did a website help drill the hole in his skull and pass the biopsy needle in to his brain? Oh sure, I bet you could find pictures of how it’s done on the internet, but when it came to performing the procedure and delivering the care, where were Google, IBM, and Microsoft on this one?
Finally, when it came time to break the news of the diagnosis to Senator Kennedy and his family, were these corporate Goliaths in the room hold hands and lend support and nurturance? Hardly. Did the family consult the wellness bureaucrats to plan the next steps when anxiety was high and trust and respect are critical?
No, it was the Davids of healthcare – the doctors and their patients – that did the dirty, yet critically important, work together. It is the Davids that form the cellular basis of the healthcare system – the cornerstone upon which the entire dysfunctional system rests - not a computer, or a website, or a hospital, or an insurer.
And disease happens. It happens while doctors are filling out the 119 items on the EMR to keep their ranking. It happens while patients are typing in their website that redirects money and attention away from the front-line care. The doctor-patient relationship is threatened like never before. With fewer primary care physicians and more and more “physician” extenders, the word “doctor” has now been replaced with “provider.” Should we spend millions on information technology infrastructure while ignoring the resources required for the than the hands-on, “mano-a-mano,” aspects of healthcare that are so critically needed today? I guess the philosophical discussion comes down to what medicine is all about. Is it about the money? Or is it about the care of the patient?
Unfortunately, it’s probably about both, for if we run out of money, we can no longer care for patients. I acknowledge the Goliaths' potential to impose dramatic market forces to control costs if they could generate healthcare price transparency. But will the hospitals and insurers ever end their little profitable healthcare pricing collusion schemes and make their closely held data available for all to see?
But when I get sick, it’s going to be all about me. And I admit, when I get sick, I might turn to Google to show me some possible diagnoses, or to list side-effects or drug interactions that might occur with my medications, or to keep that list up to date, as long as my fingers will be able to pound on a keyboard. But despite how much information gets pumped to me, I will still need a doctor with experience to help guide me toward the best course of treatment for me – one who can cull through the morass and has seen and touched someone with my condition before. Knowledge, judgement, and experience trump mere information and marketing every time in healthcare.
While some information is important, websites won’t fill the patient care void in healthcare that exists today. Certainly, they'll fill a few gaps that exist. And perhaps our goal should be to strive for "concierge medicine at Wal-Mart prices" (h/t KevinMD). Will PMR's and EMR's and home monitoring services permit this? Where's the profit in that for all those Goliaths?
E-health initiatives, therefore, are one just one more tool for the patients, the doctors, and the marketers. And while Electronic Medical Records do improve efficiencies on many levels: data retrieval, billing and coding compliance, accounts receivable, etc., but they do not treat patients nor always have their best interests at heart. Does this Great and Powerful Oz really provide something that will save us? Or does he provide bells and whistles while medicine becomes less and less humanistic? For instance, do we really need daily complete blood counts and electrolyte measurements in our default admission order sets? Certainly the hospitals benefit with higher revenues. Or might less frequent labs suffice? How much has this single default order set cost our patients? How much has it saved in terms of earlier detection of infections? No one knows.
But we do know that a doctor sifting through pages and pages of Personal Medical Record information will have less time at the bedside. We do know that there will be legal exposures if that data presented is incomplete or incorrect. So the debate goes on. But one thing is for sure, before we spend millions and millions on websites that are still unproven to reduce costs or improve care, we better be damned sure that we’re spending our limited healthcare resources wisely in the name of “Computer-Driven Healthcare.”
-Wes
Addendum: 11:30 AM CST 23 May 2008 - Matt's rebuttal is up. What'dya think?
1. Consumer-Driven Healthcare-- crock or crusade?
2. Doctor and hospital ratings-- fad or phenomenon?
3. John & Jane Doe-- patients or consumers?
I'm starting, then they'll counter, then I get a rebuttal, and so forth. Hopefully, it'll be entertaining and informative. Feel free to join in and make your thoughts known (I don't mind being handed my fanny once in a while.)
Unfortunately, I have to go first, so here goes...
Pete and Matt are right. E-health is all about the patient. Really it is.
After all, the Goliaths of Business tell us so.
You know them: Google, Microsoft, Walmart, Walgreens, IBM, Aetna, UnitedHealth, MedCo, Blue Cross, Quest Diagnostics and many, many many others. All told, as of 20 May 2008, the valuation of these companies alone exceeds $953 billion (yes, that’s right, nearly one trillion) dollars: a sum that is half the entire domestic product of all of China and a formidable sum to even begin to comprehend.
You the Consumer
With that purchasing power, we are now only too happy to hear that they are all about health, too. No doubt some of this corporate response is driven by the need to simplify an abysmally complex healthcare delivery system and Byzantine medical billing systems. But just as probably because the nation’s healthcare tab exceeds $2.3 trillion dollars and represents a rich cornucopia of new revenue streams. So, like knights with really shiny armor, each is ready to swoop down to rescue the healthcare system and its "consumers" with nothing but pure beneficence as their goal. Yes, dear patients, they’re all about you, the "consumer" and your "wellness."
After all, you are entitled to any healthcare you want. You deserve the best, the newest, the shiniest, the most plush accommodations. Anytime, anywhere, 24/7. You, dear consumer, can have it all. Oh, it might cost you a bit, sure. But our ever-friendly insurers are here to help with that. Just please, keep “consuming,” for when you consume healthcare services, you feed the beast that feeds our new economy. Our business partners will be sure to provide the information about your choices for hospitals and doctors and testing facilities for “screenings” and “prevention” right at your fingertips. And because they know that each state has different rules and different insurance policies, they’ll even allow you to filter the choices by where you live!
But that’s not all. Many will also provide you with the “best” hospitals and rehab facilities for your care, complete with rankings, too. No doubt they’ll steer you to the plan that suits you and your budget, dear consumer, the best. Have fun choosing. (Just be sure to make the right choice, will you, lest you be stuck paying a $105,000 cover charge for your cancer treatment.)
So they make websites. Quite expensive websites. Unfortunately, these websites might not save costs to our healthcare system, but heck, who cares? It's all about you, the healthcare consumer computer-surfer, remember? After all, they won't be built with the Goliath's money, mind you, but yours. Personal Health Records and informational sites. Tons and tons of them. Some better organized than others – some with pleasing color schemes and most with lots of smiling faces. And each of these sites will promise to house healthcare needs (and portions of your medical record) under one roof, provided you give your “permission.” For some, you can even grant other pharmacy, laboratory and hospital services to upload your medication, laboratory, and procedural information, too – all neatly organized. What's not to like?
But God help you if you make a typographical error or your name is a common one like John Smith (he'll need his Social Security Number and date of birth to differentiate himself from the other John Smiths out there – while providing yet another exposure for identity theft – but, hey, the information will just be used for healthcare – and maybe a bit of advertising). You see, unique identifiers are a challenge to healthcare databases. It’s tough to know you’ve got the right “John Smith” when databases are shared. The wrong “merge” and voila, you got a whole new set of preexisting conditions that the insurers can use to crank your premiums. Who will help rectify the situation? What about the other “John Smith’s” privacy? Oops.
Rankings Schmankings
True, Personal Health Records and informational websites can have answers to your questions. They have forums. They have information on your doctors and hospitals – like credentials and rankings. But these rankings are created by many, many sources: the government, marketing firms, and advertisers. Each of these ranking systems have significant limitations and use criteria that are non-uniform and only intermittently updated and almost never verified. (That, my friends, would take innumerable man-hours to maintain.) But they all claim they are the best at helping you choose your doctor or hospital with no proof as to their effectiveness. * Sigh *
Now is there a ranking that identifies the quality doctors based on the time they take with you, or if they answer your questions, or act as your advocate or evaluates your actual treatment outcomes? No. Instead, we are told that "quality doctors" are the ones that give aspirin 100% of the time after a heart attack, or prescribe beta blockers for heart failure. THAT, my friends, is just two of the ever-expanding 119 major measures that we should strive for! And these same rankings are often used for marketing of healthcare facilities. Heck, some hospitals with carefully collected quality assurance measures even pay to have their doctors “ranked” since their data always looks so good! All to help you, dear consumer, to make the right choice. After all, it is much easier (and politically correct) to implement e-health initiatives that hire more bureaucrats than to simplify the bureaucracy and redundancy by cutting unnecessary jobs!
Oh, and yes, they own all of the data. Your healthcare data.
That’s right, not you. Them.
And the Goliaths carry nary a liability concern regarding its accuracy – you saw that disclaimer, didn’t you? And don't forget, all of this data is no longer officially protected by the Health Insurance Portability and Accountability Act. Bits and bytes galore, all whirring this way and that for any number of eyes to see. All without any recourse or tracking capability and all at the speed of light. Because you, my friend, have authorized "sharing." But that’s not all. On some sights you’ll be targeted with advertisements to "empower" your healthcare choices. For many companies, this is the business model for their survival. So just how “secure” is your healthcare information if keywords you’ve entered are triggering the ads placed on your webpage? And although the Goliaths want to compare the security of banking transactions to healthcare transactions, are not the issues of identity theft real for both types of transactions? Correcting your widely disseminated “personal record” after it's been compromised is nearly impossible once the imprint of a preexisting conditions exists on your record. Good luck contacting Google to straighten that out.
The Goliaths, my friends, may soon become the Great and Powerful Oz of Healthcare, conveniently hiding their liability (and profit motives) behind a great electronic curtain called the Internet.
The PMR is not the EMR
But we mustn’t be too harsh. There are really good aspects to the personal health record and informational websites. Where else is there universal ability to transport your healthcare information between disparate institutions? Where else can you get a relatively unbiased search of information? Where else can you empower yourself with an avalanche of mostly reliable information and share experiences with total strangers who may have endured your same ordeal. But we mustn’t confuse the Personal Health Record, editable by all, as an Electronic Medical Record (EMR). The EMR contains the official transcript of your healthcare received. The EMR is the ultimate arbiter of healthcare delivery that is the undisputed king of records used in liability proceedings. As such, there is little incentive for physicians to maintain two sets of records. The Personal Health Record is just that: personal. It is NOT a health record. Sorry.
And if you want to have a Personal Health Record, you’d better not be too sick. If you can’t type or see, Personal Health Records and computer-driven healthcare might not be in your best interest, but there certainly might be a place for a caregiver to follow your healthcare delivery. Personal health sites leave a huge gap for services since they assume all "patient-consumers" use or have access to computers and will shop for “healthcare” like the latest dress or are physically and emotionally capable to use the sites as intended.
And what does this Goliathian healthcare look like on the ground? I'm just not sure yet. One only needs to look at the recent unfortunate recent circumstances of Senator Ted Kennedy to begin to comprehend the issues.
Imagine. Senator Kennedy comes into the ER with confusion, obtundation, and maybe not moving his right side very well. Did the doctors rush to Google and type in his symptoms? Oh, they could have. And they would have been met with a differential diagnosis of 870 different entries with AIDS, Creutzfeldt-Jakob disease, and inflammatory disease of the brain as the first three results after only 0.35-0.48 seconds. Hardly an accurate assessment, as we’ve seen.
And what about those hospital rankings to choose a hospital? Did the Kennedy's have a choice where he went first? Not really. He was appropriately taken to the closest facility. But more importantly as WhiteCoat has already pointed out, the family opted not to stay at that “Top 100” hospital, but rather elected to transfer him to an unranked hospital: Massachusetts General Hospital. So given all the different ranking systems out there, which ranking mechanism will you, dear “consumer,” use to make your choice of healthcare facility? Could it be that these marketing gimmicks called “rankings” might not have your best interests in mind?
And how about his diagnosis? Did a website help drill the hole in his skull and pass the biopsy needle in to his brain? Oh sure, I bet you could find pictures of how it’s done on the internet, but when it came to performing the procedure and delivering the care, where were Google, IBM, and Microsoft on this one?
Finally, when it came time to break the news of the diagnosis to Senator Kennedy and his family, were these corporate Goliaths in the room hold hands and lend support and nurturance? Hardly. Did the family consult the wellness bureaucrats to plan the next steps when anxiety was high and trust and respect are critical?
No, it was the Davids of healthcare – the doctors and their patients – that did the dirty, yet critically important, work together. It is the Davids that form the cellular basis of the healthcare system – the cornerstone upon which the entire dysfunctional system rests - not a computer, or a website, or a hospital, or an insurer.
And disease happens. It happens while doctors are filling out the 119 items on the EMR to keep their ranking. It happens while patients are typing in their website that redirects money and attention away from the front-line care. The doctor-patient relationship is threatened like never before. With fewer primary care physicians and more and more “physician” extenders, the word “doctor” has now been replaced with “provider.” Should we spend millions on information technology infrastructure while ignoring the resources required for the than the hands-on, “mano-a-mano,” aspects of healthcare that are so critically needed today? I guess the philosophical discussion comes down to what medicine is all about. Is it about the money? Or is it about the care of the patient?
Unfortunately, it’s probably about both, for if we run out of money, we can no longer care for patients. I acknowledge the Goliaths' potential to impose dramatic market forces to control costs if they could generate healthcare price transparency. But will the hospitals and insurers ever end their little profitable healthcare pricing collusion schemes and make their closely held data available for all to see?
But when I get sick, it’s going to be all about me. And I admit, when I get sick, I might turn to Google to show me some possible diagnoses, or to list side-effects or drug interactions that might occur with my medications, or to keep that list up to date, as long as my fingers will be able to pound on a keyboard. But despite how much information gets pumped to me, I will still need a doctor with experience to help guide me toward the best course of treatment for me – one who can cull through the morass and has seen and touched someone with my condition before. Knowledge, judgement, and experience trump mere information and marketing every time in healthcare.
While some information is important, websites won’t fill the patient care void in healthcare that exists today. Certainly, they'll fill a few gaps that exist. And perhaps our goal should be to strive for "concierge medicine at Wal-Mart prices" (h/t KevinMD). Will PMR's and EMR's and home monitoring services permit this? Where's the profit in that for all those Goliaths?
E-health initiatives, therefore, are one just one more tool for the patients, the doctors, and the marketers. And while Electronic Medical Records do improve efficiencies on many levels: data retrieval, billing and coding compliance, accounts receivable, etc., but they do not treat patients nor always have their best interests at heart. Does this Great and Powerful Oz really provide something that will save us? Or does he provide bells and whistles while medicine becomes less and less humanistic? For instance, do we really need daily complete blood counts and electrolyte measurements in our default admission order sets? Certainly the hospitals benefit with higher revenues. Or might less frequent labs suffice? How much has this single default order set cost our patients? How much has it saved in terms of earlier detection of infections? No one knows.
But we do know that a doctor sifting through pages and pages of Personal Medical Record information will have less time at the bedside. We do know that there will be legal exposures if that data presented is incomplete or incorrect. So the debate goes on. But one thing is for sure, before we spend millions and millions on websites that are still unproven to reduce costs or improve care, we better be damned sure that we’re spending our limited healthcare resources wisely in the name of “Computer-Driven Healthcare.”
-Wes
Addendum: 11:30 AM CST 23 May 2008 - Matt's rebuttal is up. What'dya think?
Tuesday, May 20, 2008
EKG Du Jour - # 7
"Hey, Dr. Wes, I was reading EKGs and saw one of your patient's EKG today. The pacemaker was doing something funky and I was wondering if you could check it out:"
So what's going on? Is this normal or not?
-Wes
Click image to enlarge
So what's going on? Is this normal or not?
-Wes
Star Wars, Episode IV: A New Hope?
Upon returning from the Heart Rhythm Society Meeting, I strapped in.
User ID: * click click click click *
Password: * click click click click click click *
Good morning Master Luke.
In-basket: 250 e-mails, Order Cosign: 324; Results Review: 124…
Use the Force, Luke!
* click click click click click click click click click *
But I, I can’t, ugh, I’m trying… * click click click click click *
… Phone Calls: 2; ED Follow-up: 9, Overdue Results: 32…
Come on, Luke! Focus!. Use the Force!…
… Pre-surgery notification: 34; Staff message: 3; Review reports: 2...
Small chirping sounds are heard from behind my seat. Then a voice: “Master Luke, I think C3PO has been hit!”
Focusing now…
“Urology Grand Rounds will be held 5/15/2008 at…” * click *
“Employee Appreciation Day…” * click *
“New opportunities to learn Word, Excel…” * click *
“Link Update: …” * click *
“Canceled: Clinical Section Meeting 5/21/08…” * click *
“Epic Downtime Notice…” * click *
Yes, Luke, Yes!
* click click click click click click click *
Smoke clearly perceived from back of computer guidance system… “Master Luke, our engine! What are we going to do? You’re needed in the lab, then the ward! There’s just too many of them!”
* click click click click click *
The Force Luke! Use the Force!
“Leadership Conference to be held..." * click *
“Google Alert: Google Health launched to great acclaim. Patients now will have their own personal health records and soon they may be able to communicate directly with their doctor via e-mail…”
“Noooo! I'm not sure I can... There’s too many! Ugh!” * click * “Ugh! I’m… trying…” * click *
The Force, Luke!!!
* click *
* click *
.
.
.
* click *
.
.
.* click *
Would you like to Log Off?
Yes, Luke, that’s it!!!!! Now, Luke, N…O…W…!!!!!
Closing his eyes...
* click *
Then a moment later:
* Bbbbzzzaaaappppppp *
A large flash occurs, then the screen goes dark… then...
silence....
Yes, Jedi Master. On to rounds now…
... and may the Force be with you.
-Wes
Monday, May 19, 2008
Women's Heart Health: The Perils of Nonconformity
According to the American Heart Association, Minneapolis, MN, home of all three of the major medical device manufacturers (Medtronic, Boston Scientific, and St. Jude Medical) was the most "heart friendly" city in their recently-released ranking of the most Heart Friendly Cities for Women.*
Nashville, TN was heralded as the worst city. (St. Louis, Detroit, Pittsburgh, Dallas-Fort Worth-Arlington, Columbus, Cincinnati, Las Vegas, Cleveland and Indianapolis round out the loser list.)
Wow.
Now cities have rankings compiled by donation amounts to the American Heart Association! Go Red!
So come on now, Nashville and other bastions of womanly insensitivity. Stop being so policitally incorrect! Get your act straight, for goodness sake! Take it from us guys. Conform.
Or else you're going to keep getting, er, well, um, publically bitch-slapped by the American Heart Association.
-Wes
* Please note Minnesota's obesity ranking.
Nashville, TN was heralded as the worst city. (St. Louis, Detroit, Pittsburgh, Dallas-Fort Worth-Arlington, Columbus, Cincinnati, Las Vegas, Cleveland and Indianapolis round out the loser list.)
Wow.
Now cities have rankings compiled by donation amounts to the American Heart Association! Go Red!
So come on now, Nashville and other bastions of womanly insensitivity. Stop being so policitally incorrect! Get your act straight, for goodness sake! Take it from us guys. Conform.
Or else you're going to keep getting, er, well, um, publically bitch-slapped by the American Heart Association.
-Wes
* Please note Minnesota's obesity ranking.
Sunday, May 18, 2008
Best Trick from the HRS Meeting
For all the electrophysiologists out there, the best trick for crossing the interatrial septum that is resistant to transseptal puncture came from the group in Pessac Bordeaux, France.
Although rare, these authors found that 6 of 280 (2%) of transseptal crossings were difficult. They proposed a simple solution: After they ensured accurate positioning of the transseptal sheath and needle on the interactrial septum, they applied unipolar radiofrequency electrocautery energy at 20W (using it's "cut" setting) to the needle within the sheath and advanced the needle slightly against the septum to cross. The contact was achieved outside the patient at the proximal end of the needle with the energy transmitted to its tip. RF energy was effective at perforating the septum in all 6 patient's in 4 +/- 4 seconds and no complications occurred.
Nice.
-Wes
Reference: A Straightforward Solution for Interatrial Septae Resistant to Transseptal Punctures. Knecht S, Matsuo S, Wright M, et al. Hopital cardiologique du Haut L'Eveque, Pessac Bordeaux, France. Poster PO5-41, Heart Rhythm VolL 5, Issue 5S, May 2008.
Although rare, these authors found that 6 of 280 (2%) of transseptal crossings were difficult. They proposed a simple solution: After they ensured accurate positioning of the transseptal sheath and needle on the interactrial septum, they applied unipolar radiofrequency electrocautery energy at 20W (using it's "cut" setting) to the needle within the sheath and advanced the needle slightly against the septum to cross. The contact was achieved outside the patient at the proximal end of the needle with the energy transmitted to its tip. RF energy was effective at perforating the septum in all 6 patient's in 4 +/- 4 seconds and no complications occurred.
Nice.
-Wes
Reference: A Straightforward Solution for Interatrial Septae Resistant to Transseptal Punctures. Knecht S, Matsuo S, Wright M, et al. Hopital cardiologique du Haut L'Eveque, Pessac Bordeaux, France. Poster PO5-41, Heart Rhythm VolL 5, Issue 5S, May 2008.
Friday, May 16, 2008
New Technologies for Atrial Fibrillation Ablation
One of the highlights of the Heart Rhythm Society 2008 meeting in San Francisco was the “EP TV” live cases performed today. In the morning were two ventricular tachycardia cases, and the afternoon, two atrial fibrillation ablation cases. They were professional and very well-attended.
One of the more interesting interactions occurred in the afternoon atrial fibrillation case discussions which included doctors Warren M. “Sonny” Jackman, MD (Oklahoma City, OK), Fred Morady, MD (Ann Arbor, MI), Andrea Natale, MD (his lab was operating – Austin, TX), Douglas Packer, MD (Rochester, MN), and Koonlawee N. Nademanee, MD (Inglewood, CA) as panelists and John D. Day, MD (Salt Lake City, UT) as moderator. There were two paroxysmal atrial fibrillation cases being performed – one with manual catheter manipulation and CartoSound ultrasound image development, and the other using the Hansen robotic mapping system coupled with the ESI Nav-X 3D mapping system that used their new “Fusion” software to superimpose a pre-procedural-obtained CT volume rendered image over the Nav-X geometry.
I have attempted to paraphrase the commentary (taken from notes taken) in response to a question e-mailed to the participants from the audience:
“What does the image overlay and all of this technology add to doing this procedure?”
Jackman: Well, with the known limitations of registration with these systems, I am cautious when using them. CartoSound is okay, because you’re imaging the surface of the heart directly. And certainly pre-operative CT imaging is helpful to understand the anatomy. But I would have wanted to get a feeling for this arrhythmia first (the patient was in sinus rhythm at the time) – I would want to initiate the rhythm first to see if there might be something I might understand to ablate before proceeding with the whole afib ablation. I might not find anything else most of the time, but if I did it’d be helpful.
Nademanee: I just use Carto to create a very simple map – you know, the His, CS, and pulmonary veins and use about 6-7 minutes of fluoro for the whole case after the geometry is developed – I don’t think Stereotaxis would help reduce that time very much. I use image guidance with fluoro, because my technique uses electrograms and I’m going to move that catheter because my technique relies on proper electrograms.
Morady: I don’t think there is a dispute over the role for 3D mapping of the left atrium – it cuts down on fluoro, and registering the locations of the ablation points is helpful. The extra imaging with “Merge” and CartoSound is nice but it could be that a mistake if 1-2 mm will be the difference between thinking you’re in the left atrial appendage or the ridge outside the left superior pulmonary vein. We still need a cost-benefit evaluation. Will outcomes be better? I don’t know. In the top labs around the world, they’ve ben doing a pretty good job already – it’s hard for me to think it’ll be improved with this technology.
Day: Andrea, tool or toy?
Natale: In the hands of people who do this everyday, it might not be that helpful, but for people who don’t do it everyday, I think it will be useful.
Packer: I agree with Fred’s (Morady) comments. In the more complicated cases, the utility of 3D images increases our success we think. We’ve done validation (on accuracy) with CT images. CT’s are yesterday’s news, ultrasound is today’s. Ultrasound gives about a 2mm error, vs. 3D mapping systems that give 6-8 mm error. How fast can we do it? How much does it cost. We’ve found we’re doing less pre-procedure CT’s with ultrasound now… The utility of all of this will need to be sorted out in prospective randomized trials…
Hopefully this will give a flavor for their enthusiasm. Consider purchasing the actual CD for the actual conversations from the Heart Rhythm Society if you’d like to hear more…
-Wes
Addendum: The funniest moment of the whole event was when Rodney P. Horton, M.D was introducing his atrial fibrillation case. Imagine, a room the size of two or three football fields full of cardiac electrophysiologists from around the world, analysts from every major venture capital firm in this space, and tons of industry personnel - all whom have collectively performed thousands upon thousands of catheter ablation procedures for atrial fibrillation. Then Dr. Horton says:
"...atrial fibrillation is an experimental procedure and is not approved by the FDA..."
and there, lying on the table is a patient with a Hansen robot in their leg (approved by the FDA) and an ESI mapping system (approved by the FDA) mapping their heart.
The whole room started quietly chuckling...
...like anyone cared. Now, it seems, every operation performed in the US will have to be "approved by the FDA" before it can occur.
-Wes
One of the more interesting interactions occurred in the afternoon atrial fibrillation case discussions which included doctors Warren M. “Sonny” Jackman, MD (Oklahoma City, OK), Fred Morady, MD (Ann Arbor, MI), Andrea Natale, MD (his lab was operating – Austin, TX), Douglas Packer, MD (Rochester, MN), and Koonlawee N. Nademanee, MD (Inglewood, CA) as panelists and John D. Day, MD (Salt Lake City, UT) as moderator. There were two paroxysmal atrial fibrillation cases being performed – one with manual catheter manipulation and CartoSound ultrasound image development, and the other using the Hansen robotic mapping system coupled with the ESI Nav-X 3D mapping system that used their new “Fusion” software to superimpose a pre-procedural-obtained CT volume rendered image over the Nav-X geometry.
I have attempted to paraphrase the commentary (taken from notes taken) in response to a question e-mailed to the participants from the audience:
“What does the image overlay and all of this technology add to doing this procedure?”
Jackman: Well, with the known limitations of registration with these systems, I am cautious when using them. CartoSound is okay, because you’re imaging the surface of the heart directly. And certainly pre-operative CT imaging is helpful to understand the anatomy. But I would have wanted to get a feeling for this arrhythmia first (the patient was in sinus rhythm at the time) – I would want to initiate the rhythm first to see if there might be something I might understand to ablate before proceeding with the whole afib ablation. I might not find anything else most of the time, but if I did it’d be helpful.
Nademanee: I just use Carto to create a very simple map – you know, the His, CS, and pulmonary veins and use about 6-7 minutes of fluoro for the whole case after the geometry is developed – I don’t think Stereotaxis would help reduce that time very much. I use image guidance with fluoro, because my technique uses electrograms and I’m going to move that catheter because my technique relies on proper electrograms.
Morady: I don’t think there is a dispute over the role for 3D mapping of the left atrium – it cuts down on fluoro, and registering the locations of the ablation points is helpful. The extra imaging with “Merge” and CartoSound is nice but it could be that a mistake if 1-2 mm will be the difference between thinking you’re in the left atrial appendage or the ridge outside the left superior pulmonary vein. We still need a cost-benefit evaluation. Will outcomes be better? I don’t know. In the top labs around the world, they’ve ben doing a pretty good job already – it’s hard for me to think it’ll be improved with this technology.
Day: Andrea, tool or toy?
Natale: In the hands of people who do this everyday, it might not be that helpful, but for people who don’t do it everyday, I think it will be useful.
Packer: I agree with Fred’s (Morady) comments. In the more complicated cases, the utility of 3D images increases our success we think. We’ve done validation (on accuracy) with CT images. CT’s are yesterday’s news, ultrasound is today’s. Ultrasound gives about a 2mm error, vs. 3D mapping systems that give 6-8 mm error. How fast can we do it? How much does it cost. We’ve found we’re doing less pre-procedure CT’s with ultrasound now… The utility of all of this will need to be sorted out in prospective randomized trials…
Hopefully this will give a flavor for their enthusiasm. Consider purchasing the actual CD for the actual conversations from the Heart Rhythm Society if you’d like to hear more…
-Wes
Addendum: The funniest moment of the whole event was when Rodney P. Horton, M.D was introducing his atrial fibrillation case. Imagine, a room the size of two or three football fields full of cardiac electrophysiologists from around the world, analysts from every major venture capital firm in this space, and tons of industry personnel - all whom have collectively performed thousands upon thousands of catheter ablation procedures for atrial fibrillation. Then Dr. Horton says:
"...atrial fibrillation is an experimental procedure and is not approved by the FDA..."
and there, lying on the table is a patient with a Hansen robot in their leg (approved by the FDA) and an ESI mapping system (approved by the FDA) mapping their heart.
The whole room started quietly chuckling...
...like anyone cared. Now, it seems, every operation performed in the US will have to be "approved by the FDA" before it can occur.
-Wes
Heart Rhythm Society Meeting 2008: A Conversation Overheard
“I always enjoy meeting old friends at this meeting.”
“Me, too.”
“Learned anything?”
“A few things, but there doesn’t seem to be much new.”
“I know what you mean.”
“It just seems to be the same old researchers and companies. But there's just so much more over-the-top marketing going on. God, if I see one more 256-color mapping system with little dots all over the left atrium, all claiming to be better than the next system, I'm gonna puke! There must be huge budgets to promote this stuff – most of which does help a rat’s ass at fixin’ the frickin’ afib – it looks more like a radiology meeting than an EP meeting. And did you see? Boston Scientific miraculously got their new devices approved by the FDA three to four months earlier than expected they said and yet, boy, somehow they had all the displays up already – like they “knew” all along! What a crock...."
* * * Laughing * * *
“Hey, do you know what that (Medtronic) ‘Vision 3D’ on that go-cart over there means?”
“No. Do you?”
“No clue. But man, did you see it’s plastered on the sides of the buildings and the stairs and frickin’ everywhere?. I heard someone say they got pissed that they were out-marketed by the other guys at last year’s conference, so they decided to go all out this year. I do kind of like those little go-cart thingies... maybe they should use those as shuttles to the hotels..."
“The commercialism just seems over-the-top. The *&#$*# poster sessions were like an afterthought – HRS gave more convention floor space to the companies than the poster display areas. There were so many people, I couldn’t even walk between the rows of posters! All that work – overshadowed by corporate displays.”
“Yeah, I know what you mean. The abstract sessions today – you know, the good, stuff – I heard there were 23 different sessions running concurrently. How could we even see a small portion of that?”
“You know what I think?”
“What?”
“I think that if they keep this up, that lots of folks will stop coming and just wait to see the presentations online.”
-Wes
Wednesday, May 14, 2008
Tuesday, May 13, 2008
Medtronic's Sprint Fidelis Performance Lead Update
It's now been six months since Medtronic's lead recall of their 7-French Model 6949 Sprint Fidelis defibrillator lead in October 2007. The first update of the lead performance arrived in my office this week, dated 7 May 2008 (you can view it here). With this letter came the first trending data of the failure rates as determined by evaluation of Medtronic's Carelink follow-up database and Returned Product Analysis (RPA) reports as well.While the number of lead failures remains relatively small and current follow-up recommendations have not changed, the failure trends, albeit early, remain concerning. It appears that a continued number of failures throughout the life of the lead can be expected. By Medtronic's analysis of a typical 1000-patient ICD clinic, over the next 12 months, nine (9) patients can be expected to have an anode or cathode failure and half of those patient's will have little warning of an impending fracture.
The implications of these recommendations are far-reaching, for it now seems the fault with the lead was not a physician implant technique problem as originally surmised, but rather a design flaw. Further, when it comes to replacing these patient's defibrillator batteries over the next four or five years, electrophysiologists will likely be advised to replace the 6949 lead with a more reliable defibrillator lead model, like the 6947, increasing the difficulty of a typical device battery change procedure.
-Wes
Physician Gain-Sharing: What a Tangled Web We Weave
In an effort to control costs, it seems the Department of Health and Human Services is exploring physician gain-sharing programs:
Are we potentially robbing the poor to pay the rich with this approach?
-Wes
The Health and Human Services Office of Inspector General has approved a handful of gainsharing arrangements in which physicians receive cash payments for reducing hospital spending. Gainsharing might reduce costs by aligning hospital and physician incentives, but concerns remain about quality and access.But there are significant concerns with this approach:
Although the approved programs incorporated safeguards, questions remain regarding whether such narrowly structured programs can effectively reduce costs without harming access and quality. Specific concerns focus on whether physicians respond to gainsharing by limiting their use of quality-improving but costly devices ("stinting") or by treating only healthier patients ("cherry-picking") and avoiding sicker patients ("steering") at their gainsharing hospitals. Because of concerns about cherry-picking and steering, the OIG prohibits payouts to physicians with changes in their patient mix, measured by the prevalence of high-cost, high-risk patients. The OIG also has expressed concern that physicians would increase their caseloads within gainsharing programs, essentially receiving payments for referrals. To limit this, the OIG has required that any savings generated by an increased volume of patients insured by Medicare or Medicaid could not be included in physicians’ payouts. Others have expressed concern that gainsharing might limit patients’ access to new, beneficial drugs and devices.Note that the "savings" are passed on to the hospital and doctor, but not the patient (nor their insurer).
Are we potentially robbing the poor to pay the rich with this approach?
-Wes
Radiologists Have All the Fun
I found this from this week's Grand Rounds over at Health Business Blog. Very funny.
Damn radiologists have all the best party gags...
-Wes
Damn radiologists have all the best party gags...
-Wes
HRS: Be Sure to Bring Your Lomotil
I'll be heading to the Heart Rhythm Society Meeting in San Francisco tomorrow, and just received this e-mail:
-Wes
Dear Heart Rhythm 2008 Attendees and Exhibitors,Gee, I can't wait...
The Heart Rhythm Society has learned from the San Francisco Department of Public Health that there have been reported cases of what is suspected to be norovirus in the San Francisco area. A number of those affected were attending an earlier event at the Moscone Convention Center.
As you know, Heart Rhythm 2008 is scheduled to take place at the Moscone Center, May 14-17. The Convention Center and city health officials have put measures in place to disinfect the facility and are continuing with the current schedule of events. Therefore, Heart Rhythm 2008 is scheduled to continue as planned.
We will continue to update all attendees and exhibitors via e-mail and ww.HRSonline.org should new information become available.
For more information on norovirus, please visit the CDC website at http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus.htm.
We look forward to seeing you in San Francisco.
The Heart Rhythm Society
-Wes
Underpenetration of Implantable Defibrillators
One wonders if this whole mess could have been avoided if this man had had an implantable defibrillator installed before this occurred. I mean, there's such a false sense of security thinking that it's been 10 years since your heart attack, so you must not need a defibrillator.
Well, think again.
-Wes
Well, think again.
-Wes
Monday, May 12, 2008
Skinny or Fat: A-fib Ablation is Effective
Worried fat patients might not benefit as much as skinny patients after catheter ablation of atrial fibrillation?It seems it doesn't matter.
-Wes
Sunday, May 11, 2008
Consumer-Driven Healthcare
I love the term "Consumer-Driven Healthcare." It's so, well, corporate.
God forbid we call it "Patient-Driven Healthcare." At least that might make some sense.
But "Consumer-Driven Healthcare" seems to be what all the buzz is about. Learn which hospital is the highest "rated." Learn which hospitals do which procedures. Learn which hospitals give aspirin to 100% of their acute heart attack victims, or wash their hands, or have saunas and spas, or reiki, or DaVinci robots. With that Great Website out there, "consumers" are gonna have it all! Can't you hear it? "Our website will have a HUGE impact on where you'll get your care. Our website will have all of the information right at your fingertips as your clutching your chest and can't breathe! Our website will even tell you where the most non-foreign trained medical doctors are on staff and how many are board certified, and where those doctors trained - for we tap into a repository of 8,000 databases and cull the data that looks best to us! We'll even let you see how many gold stars they've
And the Average Joe (or Janet) Everyman LOVES this empowerment. I mean, what's not to like? Isn't it great? "I'm gonna know everything before I get to the hospital - and what I don't know, hell, I'm just going to look it up on the Great Website!"
What a crock of excrement.
What Joe and Janet don't realize is this: they're patients, not consumers.
If they were real consumers, they'd know what it costs to have a gallbladder removed, or what their surgeon will charge and how much he's willing to accept in payment for his services. They'd be able to talk directly to their doctor about pre-arranged fees for procedures, especially if they had no insurance. They'd have a way to negotiate with a hospital and show them the costs at other hospitals in the area. They'd also know what a hospital room, or ICU room, or operating-room-by-the-minute or Tylenol costs. And if they didn't want to pay the cost of a Tylenol, they'd be able to bring their own. But you see, that would not allow the hospital to pay for the electricity, and janitors, and cooking staff, and security force, and hoards of quality assurance coordinators and data gatherers.
Here's the newsflash: most Big Corporations are the "consumers." They buy insurance policies for many, many, many individuals. They're whom the financial and insurance industry lends an ear, not the individual patients themselves (although this might be changing slowly as more people aren't insured). And this Big Business "Consumer-Driven Healthcare" bus is being driven into your living room and computer console without a shred of evidence that it impacts (on a large scale) where patients receive their care. Here's the deal: most people go to the hospital facility closest to them. Period. They want to be near friends and family.
So all this marketing hype about "consumer-driven healthcare" means nothing - especially if you're going to try to figure out what it's going to cost you (versus your insurer) for a particular medical service. Like some asinine $5.2 million dollar website is going to make that happen?
Now I'm not saying that all the information on the web is necessarily bad. On the contrary. I firmly believe that the information on the web is helpful - even lifesaving - on occasion (can you say "Dr. Google?") Heck, just this week a neighbor of mine gradually had increasing right lower quadrant discomfort and Googled their symptoms and it suggested "appendicitis" - the correct diagnosis - prompting this individual to seek ER evaluation early. Forums and web-based support groups also can be remarkably helpful on a whole other level: they're the power of community.
But I only need to look at myself and the difficulty I have in determining who is a good doctor or a fantastic doctor, and realize even I - one working every day in the healthcare world - have a tough time telling who's okay, good, or great. That's because I don't work with dermatologists every day, or neurologists, or pathologists, or oncologists, or pulmonologists or urologists. Now I can tell you who'd I recommend as a reasonable internist (since I work with them more often), but most of them might not go to the hospital anymore, so how good is that recommendation, eh? You'll probably get whatever hospitalist is covering the ward that week when you come in sick. Good luck finding that person's credentials or being able to pick who's covering. And nursing coverage? You know, that all-important nurse-to-patient ratio that determines the real quality of care? Since your likely to know which ward you'll be admitted to, that information is irrelevant too.
Yep - the "consumer-driven healthcare" movement: leaving little to impact your real medical care (except a really cool website).
All for a cool $5.2 million bucks and counting.
-Wes
h/t: Wall Street Journal Health Blog
Image reference.
Friday, May 09, 2008
News Stereotaxis Doesn't Need
More challenges for Stereotaxis were reported today in the St. Louis Post-Dispatch. I find it interesting that it now costs an additional $400,000 to "simplify" the computer interface with this system.
With the underlying infrastructure and construction costs above and beyond the system price, they might want to consider dropping the price to improve sales instead of raising it.
-Wes
With the underlying infrastructure and construction costs above and beyond the system price, they might want to consider dropping the price to improve sales instead of raising it.
-Wes
MacGyver Moments in Medicine
I love MacGyver moments in medicine. You know, those time when you're stuck in a predicament with a sick patient and have to come up with a creative way to get out of a jam. I had mine this week.It was an elderly patient, but not too old, with recurrent incessant ventricular tachycardia and a very weak heart muscle. The rhythms were repetitive, and it was clear there was more than one morphology of the ventricular tachycardia was noted on EKG's obtained. Amiodarone, lidocaine, procainamide, beta blockers and even general anesthesia were all ineffective at stopping the rhythm, but helped slow the rhythm. She was taken for a catheter ablation, but this too was unsuccessful at finding the dominant VT - even after working on it for over eight hours, for this was not just ANY ventricular tachycardia - this was a ventricular tachycardia that was not reentrant, but triggered. And despite our best efforts, we could not figure out what the heck it took to trigger it so we could map and ablate it.
It was an ugly situation. Simply ugly.
So what better time to turn to MacGyver, that cool, calm secret agent who made his contraptions on the fly to get him out of the most difficult of circumstances. After all, if MacGyver can use two candlestick holders, a floor mat, and an electrical power cord as a makeshift defibrillator to revive a fallen comrade, he can do just about anything.
My problem was this: I had a lady with recurrent ventricular tachycardia in whom medications and ablation didn't work and in whom a defibrillator would be contraindicated if it meant she'd receive recurrent ICD firings. It was impossible to provoke her arrhythmia to see if we could even pace-terminate it. So what to do?
Well, first, I elected to leave a temporary pacing wire in her heart. Maybe, just maybe, we could overdrive pace the rhythm with an external pacer, rather than leaving her in minutes of VT or having to shock her while we treated her heart failure.
It was worth a try.
But it soon became apparent that the rapid ventricular tachycardia rate did not lend itself to an adequate comfort zone for the ICU staff to attempt pace-termination. Somehow turning on ventricular pacing at 180 b/min for a few seconds was just too nerve-wracking for the nurses and housestaff to perform reliably, and was not always effective - possibly because of the hesitancy to pace the ventricle that fast.
Implantable cardiac defibrillators have different ways to pace-terminate a rhythm - they can "burst pace" a rhythm at a certain percentage of the tachycardia cycle length for, say, eight beats at a set rate, or they can "ramp-pace" - that is, pace the rhythm with eight successively shorter beats. These pacing algorithms also respond very quickly to the arrhythmia - in seconds.
"If I could just use the algorithms in an ICD to pace her heart," I thought.
And then I had an idea. Could I connect the temporary pacing wire to an ICD? I had an old explanted one in our lab. Maybe I could use it? But the small ports where the leads plug in are difficult to access. The connections are housed inside the header of the device, shown below:
And somehow I had to attach the ICD to a pacing cable that would connect to the temporary wire, seen here:
So I took an old lead adapter that split from the "IS-1" pin connector used inside the defibrillator to two terminals and shoved some old defibrillator patch wires inside and tightened the little securing hex nuts and suturing the cable to the adapter with a little silk suture, shown here:
Then, it was just a matter of a bit of splicing and taping:
Then it just got all connected together to make a antitachycardia pacing device that could be connected to the patient's temporary pacing wire:
And the cool thing is...
... it worked like a charm: 100% pace-termination with ramp pacing at 84% of the VT cycle length within seconds.
Anyone else have such a moment?
-Wes
Healthcare: The Next Bubble?
Imagine, medical conventions are now the prized catch of the convention industry:
... will healthcare be the next bubble to pop?
-Wes
"Medical events have attracted long-staying, high-spending visitors … so everybody wants them, and any number of cities, including San Diego, New Orleans, Boston and Chicago have proclaimed themselves to be the natural home of such meetings."Increasingly, our economy has become dependent on healthcare as its economic engine:
"Whether there is enough business to go around is a seriously open question, especially with the market overbuilt as it is," Sanders said.
Chicago's newly opened $882 million McCormick Place West Building is among the facilities aiming to attract a bigger slice of the medical meeting business. So far, its sales force doesn't appear concerned about the Cleveland project.
"The competition across this industry is fierce," acknowledged Meghan Risch, a spokeswoman for the Chicago Convention and Tourism Bureau, which books the hall. "But we're not going to speculate on a project that, up to this point, doesn't have a design plan, tenants or even the ability to book future business."
Chicago was the No. 2 site for medical meetings in the U.S., behind Las Vegas, in 2006, according to the most recent data posted by the Healthcare Convention Exhibitors Association. Cleveland, which has an outdated, underutilized convention center, did not make the association's list of the top 20 host cities.
Still in early planning stages, the Cleveland project is expected to cost about $400 million, with the county picking up most of the tab, and will include 100,000 square feet of showroom space, 300,000 square feet of trade show space and a conference center. A downtown Cleveland location is expected to be selected this summer. One front-runner site is owned by Forest City Enterprises, the Cleveland-based co-developer of the Central Station mixed-use project in Chicago's South Loop.
"Fifty thousand people in a population of 1.3 million (in Cleveland) work in the medical industry, so it's now the GM of an old industrial community," said Timothy Hagan, a county commissioner. The three county commissioners approved a sales tax increase to finance the project.And despite the glut of convention space nationally and with Medicare looking at financial insolvency in the not-so-distant future, we are left to wonder...
... will healthcare be the next bubble to pop?
-Wes
Thursday, May 08, 2008
EKG Du Jour - #6
Yet another fast and furious EKG Du Jour from the EKG Hall of Shame Fame:
This time, it's a 39 year old who presents from her internist's office after complaining of a 19-year history of palpitations which occur very sporatically. She had been seen by a cardiologist previously who workup was unrevealing: no family history of sudden death or heart disease, normal physical examination, "normal EKG" and "normal echo" (except for "flattening of her mitral valve on parasternal long axis view"). She was labeled as having "probable mitral valve prolapse" and administered Atenolol 25 mg daily, without effect. You, the ever-capable EKG aficionado, obtain this EKG:
You smile, for the answer lies within. What do you tell her?
-Wes
This time, it's a 39 year old who presents from her internist's office after complaining of a 19-year history of palpitations which occur very sporatically. She had been seen by a cardiologist previously who workup was unrevealing: no family history of sudden death or heart disease, normal physical examination, "normal EKG" and "normal echo" (except for "flattening of her mitral valve on parasternal long axis view"). She was labeled as having "probable mitral valve prolapse" and administered Atenolol 25 mg daily, without effect. You, the ever-capable EKG aficionado, obtain this EKG:
Click image to enlarge
You smile, for the answer lies within. What do you tell her?
-Wes
Zombie Housestaff
Imagine, a hospital administrator's dream come true:
It won't be long 'til they place appendages carrying stethoscopes, thermometers, blood presure cuffs, EKG stickers and pulse oximeter probes complete with operational diagrams for the patient. It will be the ultimate in patient empowerment!
But there remains one question: will it come with a cup holder?
-Wes
No more handwashing.Welcome to the new world of Zombie Housestaff.
No more spread of MRSA.
No more spread of Clostridium dificile.
No need to even touch the patient!
And all for only four to seven thousand dollars a month as operating salary with no more malpractice insurance payments.
Residents and doctors never have to leave the friendly confines of their desk as they sit before the Almighty Electronic Medical Record nor expose themselves to unseemly odors.
What is it?
It won't be long 'til they place appendages carrying stethoscopes, thermometers, blood presure cuffs, EKG stickers and pulse oximeter probes complete with operational diagrams for the patient. It will be the ultimate in patient empowerment!
But there remains one question: will it come with a cup holder?
-Wes
Wednesday, May 07, 2008
The "Hidden Curriculum"
From the Chicago Tribune today:
Of course, there's the issue of new-onset "CRS:" also known as "can't remember (uh) stuff." In those cases, I occasionally ask my staff how good ol' Ms. Fatchamatacheesedip is doing. They usually can figure it out and it seems so much more personal that way...
-Wes
Indoctrination into the finer points of slang is part of what many professors call the hidden curriculum of medical school and residency training. The official course work requires reading textbooks and paying attention during medical rounds, but the rest comes from watching how older doctors and nurses actually deal with the sometimes overwhelming experience of caring for patients.Things haven't changed in the 2000's either. Personally, I really don't like when staff call a patient by their room number, but I can certainly see, with the quick turn-arounds due to business pressures, "right side, right surgery, right patient initiatives" and privacy implications of our work, why this happens.
A common slip happens when doctors refer to a patient as his or her disease—as in, "the gall bladder in Room 602" or "the P.E. [short for pulmonary embolism] who was admitted last night."
Gregory Makoul, director of Northwestern's center for communication and medicine, said such references can make doctors forget the human dimension of their decisions.
"When you start labeling someone as a disease you can't help but see them as a problem and not as a person," Makoul said. "We try to get people to recognize that, the power and detriment of that sort of label."
Some residents note that medical privacy regulations have made doctors and nurses careful about when they use a patient's name, which can encourage shorthand such as referring to patients by their disease.
Many medical slang terms revolve around the struggle to get patients in and out of the hospital as fast as possible. Schumann said such concerns reached new heights in the 1980s, when Medicare and many insurance plans began paying hospitals fixed rates according to a patient's illness, putting a premium on wrapping up care quickly.
Of course, there's the issue of new-onset "CRS:" also known as "can't remember (uh) stuff." In those cases, I occasionally ask my staff how good ol' Ms. Fatchamatacheesedip is doing. They usually can figure it out and it seems so much more personal that way...
-Wes
Grand Rounds is Up
... and there's some great writing over at Suture for a Living:
-Wes
I had no theme for this Grand Rounds, but thought I would share some links and photos of Arkansas.A humble beginning for a great edition.
-Wes
You Know You're Getting Old When...
... you find yourself making two sets of rounds in the hospital:
One for work rounds, seeing patients.
And one for social rounds, seeing friends.
This week, my social round census began to approach my work census. Hope you guys get better soon!
-Wes
One for work rounds, seeing patients.
And one for social rounds, seeing friends.
This week, my social round census began to approach my work census. Hope you guys get better soon!
-Wes
Monday, May 05, 2008
Hang On and Shock 'em
Young cardiology fellow meets electrophysiologist after an episode of new-onset atrial fibrillation that requires cardioversion in the EP lab:
-Wes
Reference: Lloyd MS, Heeke B, Walter PF, Langberg JJ. "Hands On Defibrillation. An Analysis of Electrical Current Flow Through Rescuers in Direct Contact With Patients During Biphasic Defibrillation." Circulation. 4 May 2008.
"Go ahead, hold the legs."
"Are you nuts?"
"No, I'm not nuts. You need to hold their legs so after the shock they don't bend their legs with all those catheters in them and hurt themselves."
"But you're going to use 360 Joules!"
"Yep, and you won't feel a thing."
"No way."
"Way."
"How can you be so sure?"
"Because those gloves you're wearing do not conduct electricity. Sync on? Good. Everybody clear? (No not you - you keep holding...) Go ahead."
* * * Thump * * *
"Didn't feel a thing, did you?"
"Ah, no, but now my heart is racing..."
-Wes
Reference: Lloyd MS, Heeke B, Walter PF, Langberg JJ. "Hands On Defibrillation. An Analysis of Electrical Current Flow Through Rescuers in Direct Contact With Patients During Biphasic Defibrillation." Circulation. 4 May 2008.
Subspecialist Shortages and the EMR
The growing pay gap of non-procedurally-based subspecialties is threatening acute shortages of physicians in those fields:
New pressures are mounting on proceduralists (like gastroenterologists, cardiologists, radiologists and orthopedic surgeons) to increase procedural volumes. In multispecialty groups, the Medicare reimbursement system which devalues time with patients through its arcane and toxic documentation requirements shifts the burden of revenue generation to specialists to support other subspecialties that are less profitable. High-productivity specialists are now urged to do more to cover short-falls in revenue by their business managers. Even small fluctuations in practice volumes are seen in real-time thanks to electronic billing and the Electronic Medical Record (EMR).
The EMR has become not only the administrators' friend, but the proceduralists' as well. Thanks to text-generating "macros" (sometimes called "dot-phrases") the burden of the pre-op history and physical has been all but erased. If a patient has one cataract done thirty-two days ago (outside JCAHO's 30-day requirement), well then, no problem, just hit a few "dot-phrases" and presto! Away we go! "Dot phrases" can load up an empty history and physical form faster than you can say "operation."
But this push to increase procedural volumes, so easily tracked by the electronic medical record, puts additional burdens on today's procedural specialists and creates new patient-care conflicts. Increasingly, there is a push to tie physician compensation to "productivity." Productivity, then, becomes king. And for the patient who desires careful analysis of procedural options, careful decision making becomes clouded as salaries are increasingly tied to productivity.
So for doctors, the dark underbelly of the EMR for patient care is surfacing: despite its marvelous communication capabilities and efficiencies, the EMR has now become the quintessential business oversight tool and might just threaten the doctor-patient relationship as we've known it.
-Wes
A discipline built on spending time with patients to gather clues for a diagnosis, neuro-ophthalmology could become another casualty of a medical payment system that favors high-tech procedures over low-tech exams. The median income of a neuro-ophthalmologist at a teaching hospital is $200,000, according to the North American Neuro-Ophthalmology Society. That's a third less than most general ophthalmologists, who undergo less training but can see more patients, and do more pricey procedures, in a given day.And while this is concerning, it is only the beginning of the story.
Many in health-policy circles have focused on how the current health-care payment system is helping create shortages among primary-care doctors, internists and others on the front lines of medicine. But often lost is how the system is endangering some of the country's most highly trained specialties as well.
Endocrinologists, rheumatologists and pulmonologists -- specialties that also don't involve performing many procedures -- face acute shortages. Many of the severest deficits affect children. Though nearly 300,000 children in the U.S. are diagnosed annually with juvenile arthritis, lupus or other complex rheumatic diseases, there are fewer than 200 pediatric rheumatologists to take care of them, according to the U.S. government's Health Resources and Services Administration.
New pressures are mounting on proceduralists (like gastroenterologists, cardiologists, radiologists and orthopedic surgeons) to increase procedural volumes. In multispecialty groups, the Medicare reimbursement system which devalues time with patients through its arcane and toxic documentation requirements shifts the burden of revenue generation to specialists to support other subspecialties that are less profitable. High-productivity specialists are now urged to do more to cover short-falls in revenue by their business managers. Even small fluctuations in practice volumes are seen in real-time thanks to electronic billing and the Electronic Medical Record (EMR).
The EMR has become not only the administrators' friend, but the proceduralists' as well. Thanks to text-generating "macros" (sometimes called "dot-phrases") the burden of the pre-op history and physical has been all but erased. If a patient has one cataract done thirty-two days ago (outside JCAHO's 30-day requirement), well then, no problem, just hit a few "dot-phrases" and presto! Away we go! "Dot phrases" can load up an empty history and physical form faster than you can say "operation."
But this push to increase procedural volumes, so easily tracked by the electronic medical record, puts additional burdens on today's procedural specialists and creates new patient-care conflicts. Increasingly, there is a push to tie physician compensation to "productivity." Productivity, then, becomes king. And for the patient who desires careful analysis of procedural options, careful decision making becomes clouded as salaries are increasingly tied to productivity.
So for doctors, the dark underbelly of the EMR for patient care is surfacing: despite its marvelous communication capabilities and efficiencies, the EMR has now become the quintessential business oversight tool and might just threaten the doctor-patient relationship as we've known it.
-Wes
Sunday, May 04, 2008
The Cognitive Age Paradigm and Healthcare
New York Times columnist David Brooks offered a brilliant essay in yesterday's paper:
-Wes
The chief force reshaping manufacturing is technological change (hastened by competition with other companies in Canada, Germany or down the street). Thanks to innovation, manufacturing productivity has doubled over two decades. Employers now require fewer but more highly skilled workers. Technological change affects China just as it does the America. William Overholt of the RAND Corporation has noted that between 1994 and 2004 the Chinese shed 25 million manufacturing jobs, 10 times more than the U.S.Given the new globolization of healthcare, his "cognitive age paradigm" is equally relevant to healthcare delivery.
The central process driving this is not globalization. It’s the skills revolution. We’re moving into a more demanding cognitive age. In order to thrive, people are compelled to become better at absorbing, processing and combining information. This is happening in localized and globalized sectors, and it would be happening even if you tore up every free trade deal ever inked.
The globalization paradigm emphasizes the fact that information can now travel 15,000 miles in an instant. But the most important part of information’s journey is the last few inches — the space between a person’s eyes or ears and the various regions of the brain. Does the individual have the capacity to understand the information? Does he or she have the training to exploit it? Are there cultural assumptions that distort the way it is perceived?
The globalization paradigm leads people to see economic development as a form of foreign policy, as a grand competition between nations and civilizations. These abstractions, called “the Chinese” or “the Indians,” are doing this or that. But the cognitive age paradigm emphasizes psychology, culture and pedagogy — the specific processes that foster learning. It emphasizes that different societies are being stressed in similar ways by increased demands on human capital. If you understand that you are living at the beginning of a cognitive age, you’re focusing on the real source of prosperity and understand that your anxiety is not being caused by a foreigner.
It’s not that globalization and the skills revolution are contradictory processes. But which paradigm you embrace determines which facts and remedies you emphasize.
-Wes
Saturday, May 03, 2008
Gone Viral
Yesterday, by son was on his Facebook account and was sent a "Bumper Sticker" from a friend to place on his Facebook page. He had never seen this application before, so he decided to click on the "Most Popular" button to see what other "Bumper Stickers" were on Facebook. There, third most popular, was one he recognized immediately from our MedTees site.As of last night, the image has been uploaded a remarkable 3,544,374 times on Facebook after being originally uploaded by Alec Chin Lee of St. Mary's College, Class of '09.
Wow, thanks, Alec!
-Wes
PS: Oh, and if you want your own bumper sticker (or magnet, apron, shirt, etc.) while supporting a good cause, click here.
Thursday, May 01, 2008
EKG Du Jour #5
Alright. It's gettin' near the weekend, and it's been a pretty slow week for cardiovacular news here, so I'll put up a chip-shot EKG for the clever observer from the "EKG Hall of Fame."
What's the diagnosis of this 74 year old asymptomatic man?
-Wes
Other earlier fun EKG's and rhythm strips:
EKG Du Jour #1
EKG Du Jour #2
EKG Du Jour #3
EKG Du Jour #4
What's the diagnosis of this 74 year old asymptomatic man?
Click to enlarge image
-Wes
Other earlier fun EKG's and rhythm strips:
EKG Du Jour #1
EKG Du Jour #2
EKG Du Jour #3
EKG Du Jour #4