"Before the movie "50 First Dates", there was a sci-fi short story that posited this, with horrifying consequences."

LOL,

before the movie and sci-fi story there were (and of course still are) plenty of *real* people with severe anterograde amnesia. One of the more famous cases just died

http://en.wikipedia.org/wiki/HM_(patient)

I worked with a patient who attempted suicide by asphyxiation. They survived with a profound case of anterograde amnesia. You could leave the patient room and return 30 seconds later, and the patient would have no knowledge of you or your meeting 30 secs prior. It took literally 100's of repetitions of exact sameness before any noticeable learning occured. For example, taking them from point A to point B required tracing the exact same route, multiple times per day, for months on end before this person had any sense that they were actually going to destination B and back (though they were never able to go alone).

It *may be* frustrating to the individual, if they have any sense or insight as to their condition. They may get frustrated by the frustrations of those around them. Generally speaking (*very generally speaking*) severely dementing illnesses are as hard, if not harder, on those individuals who are around the demented indivdual.

Side story: My grandmother had a pretty wicked case of Alzheimer's disease. She would call our house 10+ a morning asking is she had a doctor's appointment that day. She knew she had future appointments, just didn't know when and had no ability to remember she had just called and asked us the same question 5 minutes prior :-). So we get the brilliant idea to write down the dates and times of all appointments and post them to her refrigerator. So, then we get the calls every day, "Is it Monday?" LOL. See "Complaints of a Dutiful Daughter":

http://www.pbs.org/pov/discover/?season=1995&offset=9#film-list

For a very thoughtful and thoughtprovoking piece on Dementia. Was nominated for an academy award when it came out.

later,
jeff

No question,

it can be done. The VA's system is integrated nationwide. So when a Vet moves from one hospital to another, from one state to another, his electronic medical record travels with him. So technically, it's certainly feasible. I was unaware of the Regenstrief insitute. Thx for the link. For me, the operative paragraph is:

"The Institute receives $2.8 million per year in core support from the Regenstrief Foundation and has an annual budget of approximately $19.5 million generated by Institute investigators, largely derived from federal grants and contracts from the National Institutes of Health, the Agency for Healthcare Research and Quality, national philanthropies, Indianapolis healthcare institutions, and other sources."

They have a 20 million dollar operating budget, I suspect largely funded by soft money. Unfortunately, I can't tell what what the "subscription" costs are to the participating hospitals. But i'll bet it's minimal. Now, this is Indianapolis. Imagine the costs/complexities associated with a similar system in Chicago, LA, New York City, etc... The costs and complexities increase geometrically, I can assure you.

I'm not at all disagreeing that it can't be done, because it surely can. But the direct and indirect costs are so high that, until there are financial incentives to do so, you're just not going to see this kind of thing in very many places. Not unless some goverment entity steps in and provides considerable funding to drive an institute like the one you identified.

take care,
jeff

"4. They don't inter-operate. (When I request old records from other physicians with electronic charts, I enter the pertinent data into my electronic chart by typing it in.)
If any skilled group of software engineers were to write a decent, usable EMR that was extensible, and didn't cost an arm and a leg, with an eye to being excellent first and profitable as a consequence, they could be up for a Nobel prize. "

Whenever this topic comes up, the same answer always eventually comes out to address "4", which is of course VA's VISTA/CPRS. Not only is it customizable and extensible, but the program and code are free to anyone who wants it. And I don't see the programmers from the VA winning any Nobels any time soon ;-). Read "The Best Care Anywhere." Even if you disagree with the premise, Longman presents an interesting section on how VISTA, and later CPRS came into being. It's his position that an important (if not primary) reason there is not adoption of electronic medical records in the private sector is because it can actually create a competitive disadvantage.

Massing huge amounts of electronic, easily accessibly medical information on an individual is really only advantageous to the patient, provider and system if the patient remains with the same providers and same health care system, which of course is true for the Veterans treated by VA. Long term, detailed information on a patient is advantageous on the patient level because you can monitor more easily preventive health measures and track health status over time; for the provider it means decision making can be more informed which should improve outcomes; for the system it means better outcomes and presumably more competitive advantage. But here's the rub: patients don't stay with the same providers or same systems. Health care has become so complicated that person's change their care plan, and hence their providers and health care system often. If I'm Blue Cross, I can guarantee you I know exactly what the rollover of the person's in my panel are from year to year. If I'm a hospital administrator, I know exactly how many person's come and go through the plans I have contracts with and how many are seeking care at my facility. As you point out, unless a facility takes a stab at VISTA/CPRS, EMR's can be insanely expensive to develop. And deployment, penetration and compliance within a facility/system is a herculean task requiring a major change in culture to ensure adoption. So, as some sort of health care system administrator, for every patient that moves to another plan and hence gets care from other providers in other hospitals, I have just given my competitors an enormous advantage in their care of this patient. The patient is able to bring them their complete, beautifully printed out and organized medical record to aid their providers in the care of this person.

Now, of course, it also says I would have the same benefit when patients come to my system. The problem is who is going to budge first? And if someone else budges, and I can attract those patients to my system, then maybe I don't have a good incentive to develop an EMR for my facility in the first place. Maybe I should spend more money on a finely landscaped, aesthetically beautiful, modern bed tower? Because, really, the patient is going to leave and go elsewhere eventually. When they change jobs, their health care plans change. When life circumstances change (e.g. they now need a family plan), their health care plan changes. There's a ton reasons person's change health care plans, and very few of them have to do with actually wanting to see a certain person or get care at a specific facility. Without these lifelong relationships between patient, provider and system, it's hard to convince a facility of any size, be it a small practice of primary care providers to large health care systems buying up hospitals, to invest the time and energy in an EMR. And it will remain this way until there are clear financial incentives to do so; or the health care system is totally revamped such that lifelong relationships between patients and providers is again feasible.

later,
jeff

Couldn't it also be the case that there are an infinite number of fortuitous events, and that a person's ability to recognize and capitalize on that event is related to (amongst other things I suppose):

having natural talent
-and/or-
developing that talent through hard work and education
-and/or-
ambition
- and/or -
hard work

As someone pointed out above, it's not about luck per se, but about maximizing one's chances of being in the right place at the right time. If you operate on the assumption that there are an infinite number of fortuitous events and you have the aforementioned traits, perhaps the chances of encountering a life changing circumstance or event and capitalizing on that circumstance or event is in fact greater than it would be if you lacked the aforementioned traits.

jeff

Howard was part of the sirius standard package,

so there was no additional fee. It does appear now that he is not part of this a-la-carte packaging their doing, and if you want Howard, you have to pay for the whole package. As far as how many subscribers can be attributed to Howard, of course that's hard to say. What is true is that Sirius had some 600,000 subscribers when they signed Howard, with very negligible growth in new subscribers. Also, their deal with Howard pre-dated their deal with car manufacturers, so the rise in new subscribers after having essentially flatlined for 2 some years is basically attributed to Howard, at least for a couple years after signing that deal. The subscription count doubled, if i recall correctly from about 600,000 before they inked howard, to about 1.2 million when he actually went live. And that number doubled again a year after Stern went live. So, they essentially quadrupled their paid subscribers from the day they announced the Stern deal to approximately one year after he went on the air. Again, I understand that you can't necessarily attribute all that growth to Stern, but it's certainly more than coincidence. Finally, the estimates from '05 were that 20% of dedicated listeners would migrate to Sirius to hear Stern. Again, how many listeners he had in '04 is hard to say. But google around and you'll see estimates ranging from around 12 million to 20 million. Taking a very conservative figure of 10 million listeners, and only 20% of those listeners moving to Sirius, that's still 2 million listeners attributed to him alone.

My conerns with the deal were (a) that Stern's fan base has essentially flattened. And whatever percentage of his followers that were going to follow him to Sirius have already done so. Therefore, Sirius/XM can't expect any more growth from him. That ship has sailed. And the second was (b) when Stern cashed in an early set of options and took close to half that contract up front, rather than wait and watch the stock rise in price. That told me right there he had perhaps less confidence in the product than he could talk about on the air.

jeff

Well,

Stern easily brought somewhere between 1,000,000+ to upwards of 6,000,000+ listeners over to Sirius depending on who you read and listen to. I think the 1,000,000 is an extremely conservative estimate, but even a million subscribers at $12.95 per month (for one radio mind you. Many folks, myself included, have multiple subscriptions) works out to over 150 million a year, which certainly covers the cost of his contract. And that's assuming only 1 million new subscribers. Sirius accumulated over 1,000,000 new subscribers from the time they announced the Stern deal to the time he went on the air (or very close to it). And this was before they were sticking free radios/subscriptions in cars. There was an article in Fortune or Forbes not long after the agreement was made public that spelled out the same kind of math.

I'm not saying it wasn't an absurd contract or absurd amount of money. Of course it was. But Sirius was in the outhouse before they hired Stern. They were getting absolutely slaughtered by XM (some 10x the amount of subscribers as compared to Sirius). Now Sirius owns XM. Stern's listeners paid for his contract, and then some. However, it was such an absurd amount to offer that Sirius didn't quite reach the financial reward they could have had they not given Stern so much.

Two years ago, Sirius would have just refinanced the debt and continued to build its revenue stream. However, there is no money to borrow now, and they are in a world of hurt as a result.

jeff

LOL,

Glad you found the article thought provoking. Unfortunately, that's not the one I intended :-). This is the one I meant to link to:

http://www.washingtonmonthly.com/features/2005/0501.longman.html [washingtonmonthly.com]

The other one perhaps does overstate the reality of rolling out VistA throughout the entire US health care system :-). But I guess if president-elect OBama wants to infuse a ton of money into the development of MUMPS programers, more power to him :-).

To your other points, I agree. I don't know what they'll do to continue supporting this system as programmers migrate out/retire and there are not MUMPS programmers to replace them. I've heard and/or read about the difficulties of coding in MUMPS, but have never looked at code myself.

As you point out, the cost of developing/deploying a large scale, scalable, customizable, thorough EMR is shockingly high. And one of the reasons I think most hospital systems don't want to touch it. The cost savings are too distal, and potentially lost when you lose a patient to another plan (because they changed jobs, health care benefits, or some such thing). Every preventive measure you take now is cost savings down the road. But if that patient leaves, you've just saved your competitor money ;-).

One last thing. We do have a complete pharmacy package built in to Vista. This includes physician order entry, medication history (including active, inactive and d/c'd meds), administration, refill history, etc... Physician practice isn't really an issue here cause our clinics are all subsumed under the main hospital, so the documentation end is no different than if the patient is seen during an inpatient admission. With that said, much of our outpatient scheduling package is integrated as well. I can review past appointments, records attached to that appointment, appointment history, whether the patient no-showed, cancelled, etc..., what diagnostic and procedures codes were attached to the visit, etc...
Finally, at least at my facility, we have two long term care "nursing home" units (a total of some 200+ beds). They are also part of the facility, so again everything is simply tied to VistA. No genetics module for sure. But they've really advanced on medical imaging. For example, I can pull up both the radiology reports and complete imaging from my desktop. The remote access on the imaging module is not yet available. In other words, I can't view CT scans from another facility. But otherwise, as a provider, it certainly covers the overwhelming majority of my day-to-day record management needs, regardless of setting.

take care,
jeff

Well,

perhaps state of the art was the wrong phrase. But simply because something is riding on an old, antiquated language that hasn't seen the light of days in years doesn't take aways from it's capabilities, which I maintain are state of the art. I'll give you two quick examples, from the last few days, but experiences like what i'll describe are a daily occurence for 1000's of our providers every day.

A patient reported to me that their health and functioning have recently become worse, but that they can still do the things they needs to do to live independently. Now, it was painfully obvious just looking at at the patient that they were not capable of living independently. Their spouse reported that the patient's functioning is no worse now than it was three years ago, that the patient essentially requires total care, they have a history of anger, and is cognitively impaired. Not surprisingly, the patient disagreed with all of this. The patient has a degenerative disease, and knowing the progress is important diagnostically. The problem is that the patient was seen at three different VA's in two different states. I was easily able to pull up the patient's record from each of the other VA's, review it, and determine that the spouse's report was spot-on, despite what the patient was reporting. There was additional information contained that was important for care planning, that hadn't yet been discussed. It took maybe 1 minute to access the other sites and get to all the records.

The second example involved a patient who was reported to have been refusing medications. I pulled the patient's chart up, and reviewed each of their medications. I can tell what medications the patient is on, when they were given to the patient, who exactly gave it to them, and whether the patient takes the medication or refuses the medication. The patient, a diabetic, was only refusing their oral diabetic agent and insulin. I then pulled the lab results up, and plotted the last month of HGA1c values and could see that, while somewhat erratic, their blood sugars were still within normal limits. I spoke with the patient and their mother. Because their diet had been altered in the hospital, it was the patient's opinion that their blood sugars were relatively controlled and therefore there was no need for diabetes medication. I don't know that I necessarily *agree* with the patient's opinion, but at least I understand it. More importantly, five minutes after it had been reported that the patient was refusing medications, I knew exactly what he was refusing, and had a block of lab values to get a sense of the immediate impact the patient's decisions were having on his health. This makes a big difference when I go to speak with the patient.

The important thing is that the system we use is *all* electronic entry. Therefore, it's readable. Second, it's practically (not completely yet) universal in that no matter what VA the patient was seen at, I can get their records in a matter of minutes. Third, because it's electronic entry, there can be all kinds of checks and balances built into the system to reduce data entry errors. Take the first example, had the patient been moving through the private sector, even if they had been taking their medical records with them and happen to have them at the time I saw them, I still would need to plow through a hand written record. Even if it was digitized, that often means scanned paper/pencil records which I can assure you is a total bear to disentangle. We get referrals from the private sector all the time, and it can be a nightmare determining what's been going on with a patient.

We track pracically everything related to the health care of a patient: meds, labs, orders, notes, diagnosis, imaging, imaging results, surgery reports, pathology reports, admissions, discharges, providers, etc... And we do it for the entire system, making it all available no matter where the patient is seen. And because we track it electronically at the patient level, it can be mined at the aggregate level for systemic planning and outcomes research. One thing I do appreciate are the issues of privacy. This is *a lot* of information about an individual and we take privacy and security seriously, although I am perfectly aware of our data loss issues in the past.

I've worked at (and continue to work at) a number of major academic medical centers in a major metropolitan area, and nothing touches our system. Further, I've demo'd the system for large health care consulting firms looking to deploy similar systems to large hospitals (I'm just a little biased at how good I think our system is :-) ). They *always* walk away with this realization; they are a long way off from pushing something out remotely close to what we have in terms of integration and thoroughness. And it's not surprising. The VA's system was pushed out in 1996 (at that time, all entry was using a text editor through a terminal emmulator), with a GUI front end rolled out in 1999(?). So we have at least 10-12+ years development under our belts.

Anyway, that's the story. Although Longman's book isn't great, he does go through a fairly detailed description of our EMR and it's benefits, both short-term and long-term. This essay (I think):

http://www.washingtonmonthly.com/features/2007/0710.longman.html

was the genesis for the book.

take care,
jeff

"...works better. The only real question is our government one of the worst and least efficient at performing tasks like these and is that likely to continue? Our government has already managed some of the worst implementations of social constructs around the world. Currently our healthcare system is one of them, but there are may more..."

http://www.washingtonmonthly.com/features/2005/0501.longman.html

jeff

Well,

One of the primary reasons is that the cost savings associated with a comprehensive EMR are generally longer term, namely better coordinated management of preventive health issues. The ability to centrally track patients and their health care within your own system goes a *long* way to better coordinated care for existing illness and better preventive care for those at risk.

Now here's the rub. People switch health care plans/systems so often that I, as a health care administrator, will never realize the cost savings because the very people I'm tracking and coordinating the care of change jobs in a year and are with another health plan, with a new hospital and new primary care providers, etc... So by undergoing a massive capital investment to get a complete medical record system deployed, is likely going to benefit my competitors at least as much, if not more, than myself. Every patient that I lose to another facility gets to take with them the entire medical record I've created for them, greatly enhancing one's ability to do good care, which in this case is another competitor. On the other hand, I pick up someone who comes from a system without similar medical record management and get nothing.

Now, I work at the VA which has the most advanced, state of the art electronic medical record system on the planet, and I defy anyone to point to a large scale health care system that has one that's really better in the aggregate. So, here at the VA we don't have the same barriers to adoption that private sector hospitals consider as the great majority of our patients are with us for life, so there is value in tracking them for the long term. I certainly don't agree with the private sector barriers philosophically, but practically speaking I understand the thought processes.

And as a side note, as has been pointed out in the past when topics like this arise, the VA's entire package of electronic medical record management software is available free, for download. Now deploying it is a whole 'nother matter and a cottage industry of ex-VA computer folks have started consulting gigs helping health care facilities adopt our package. But that's a different story entirely.

hth,
jeff

"The same reasoning or lack thereof applies to the Kindle (which I don't like [wordpress.com] for its DRM and other problems), since Amazon won't release sales numbers for it. "

The title of your blog is "Product Review: Kindle" but did you actually receive and review a kindle, or are you just pointing out the reasons you wouldn't like a kindle? Nowhere in your "review" do I see mention of you actually having and using the Kindle. I just see an argument as to why you don't like it (or I guess more accurately why you don't like the idea of the Kindle) and why you don't think it will succeed. I don't own one myself, but I don't know that I see a review from the posted link in your comment either.

jeff

"The big-box retailers taking over all the specialty shops across the US are actually reducing the diversity of goods available locally (the ACE hardware actually has more depth than Lowes in many areas for example)..."

While I agree in spirit with the post, and also agree that if you don't live in a major metro area, you are limited to the stock on hand of big box retailers, I call BS on the above statement about ACE. Show me some evidence, somewhere, that any ACE hardware has greater diversity in either different products or different brands of the same product than a Lowes. Forget about *many* areas. I'll settle for one ACE hardware, anywhere, that has more different products than even the smallest Lowes. That just can't be true as even "Great ACEs"(if they have them anymore) are dwarfed in size as compared to Lowes (or Home Depot for that matter).

I'm no fan of big box retailers, and I do miss the mom-and-pop specialty retailers. But the example of ACE compared to Lowes I don't believe. Lowes and Home Depot are huge improvements over Ace and True Value as far as product availability and diversity goes.

jeff

Generally speaking,

consent to treatment isn't predicated on memory per se. Here is the link to a PDF file written by one the noted experts on competence to consent to treatment:

http://content.nejm.org/cgi/reprint/357/18/1834.pdf

The Grisso and Applebaum book "Assessing Competence to Consent for Treatment: A Guide for Physicians and Other Health Care Providers" is the defacto book for health care providers to understand and assess competence as it relates to medical decision making.

hth,
jeff

Well,

I can't speak for the parent poster, as maybe he didn't see this list. I did. And I still feel the same as the parent poster (and what many other posters have pointed out). Instead of showing a flashy video with a remarkably high "gee whiz" factor for the PHB's of the world, why not show some actual real world applications? Why not show how this thing is currently being used by some of these fortune 50 companies? At the least, present a case study or two that demonstrates the advantages of this system over a 2D environment in a much more precise manner.

For my money, there is no question it's a cool video, and certainly engenders a "I wish I had one" kind of feeling. Even though I don't have the vaguest idea what I would do with it :-). I also agree with the previous poster who pointed out that, in the late 90's, venture capitalists would have piled on to the technology simply because of the high "gee whiz" factor. PHB's fall for it time and time again and this interface certainly has it.

just my .02,
jeff