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Education

Australia To Ban Unvaccinated Children From Preschool (newscientist.com) 281

An anonymous reader quotes a report from New Scientist: No-jab, no play. So says the Australian Prime Minister, Malcolm Turnbull, who has announced that unvaccinated children will be barred from attending preschools and daycare centers. Currently, 93 percent of Australian children receive the standard childhood vaccinations, including those for measles, mumps and rubella, but the government wants to lift this to 95 percent. This is the level required to stop the spread of infectious disease and to protect children who are too young to be immunized or cannot be vaccinated for medical reasons. Childcare subsidies have been unavailable to the families of unvaccinated children since January 2016, and a version of the new "no jab, no play" policy is already in place in Victoria, New South Wales and Queensland. Other states and territories only exclude unvaccinated children from preschools during infectious disease outbreaks. The proposed policy is based on Victoria's model, which is the strictest. It requires all children attending childcare to be fully immunized, unless they have a medical exemption, such as a vaccine allergy.

Submission + - US Dept of Veterans Affairs to dump freely-available electronic health record sy

dmr001 writes: US Department of Veterans Affairs Secretary David Shulkin, MD announced to Ongress plans to transition from VistA to a commercial EHR. Despite the fact that physicians typically find VistA sensible and relatively easy to use, Shulkin feels the VA should get out of the software business and buy a "commercially tested" product. The US Department of Defense recently contracted with Cerner though that transition is already beset with delays. There's no word yet how the VA might ensure any new system will be compatible with DOD's solution. Recent attempts to upgrade VistA (originally developed in house) using outside contractors have not been clearly successful.

Submission + - SPAM: Why Your Dad's 30-Year-Old Stereo System Sounds Better Than Your New One

schwit1 writes: The receiver engineers have to devote the lion’s share of their design skills and budget to making the features work. Every year receiver manufacturers pay out more and more money (in the form of royalties and licensing fees) to Apple, Audyssey, Bluetooth, HD Radio, XM-Sirius, Dolby, DTS and other companies, and those dollars consume an ever bigger chunk of the design budget. The engineers have to make do with whatever is left to make the receiver sound good.
Link to Original Source

Comment Re:Don't use a PPI (Score 3, Informative) 102

  • 1. If I had a nickel for every time I had a heart to heart talk with a patient about improving their diet and exercise regimen to avoid the untoward consequences (reflux, overweight, diabetes, heart disease, feeling like crap in general) I'd have, like, a lot of nickels.
  • 2. Interestingly, a response I get that's more common than you'd think is "I'm not switching from Pepsi to water. I hate the taste of water." We call this "pre-contemplative."
  • 3. Some folks eat quinoa and twigs and still have risky acid reflux (with risks including esophageal cancer, bleeding, and cooking their esophagus sufficiently in acid it narrows - kind of like ceviche). While H2-blockers are first line, if they don't do the trick, sometimes proton pump inhibitors are the least worst thing.

Comment Re:you mean capitalism works? (Score 1) 372

I prescribed a vial and syringes a few hours ago. Not an EpiPen; in my case it was for a similar (but less sexy) scenario, naloxone, to use for opioid toxicity, a popular cause of death among opioid addicts and even those prescribed opiates for legitimate use. (The current recommendation is to prescribe an opiate-antagonist for those using over 50 morphine equivalents a day.) I just hope to heck if my patient ends up over-gorked on their meds they can find the syringe and draw up the medicine. (Injecting it is the easy part; you could do it through your pants blam! into the leg.) You can't keep a regular syringe pre-filled safely - the medicine doesn't stay safe. Luckily, naloxone doesn't need to be dosed carefully. Epinephrine does (too much could fry your heart). I suppose it's not so importnat to be precise as it is for insulin, but most people don't need to draw that up in a hurry.

Comment Re:That's nice.... (Score 2) 30

Blowing my mod points for the opportunity to clarify why we screen for diabetic retinopathy: By the time a diabetic patient has visible diabetic retinopathy, laser photocoagulation treatment cannot always repair the damage. The goal is to find the bleeding before risking significant visual loss, when treatment tends to be more successful. This is why most organizations (like the American Diabetes Association) recommend yearly dilated eye exams for diabetic patients. Unfortunately, screening can be expensive for underinsured or uninsured patients, or those without access to ophthalmologists or optometrists. As a primary care physician I asked if I couldn't get trained myself to save the cost for my uninsured patients, and got basically a bunch of eye-rolling. Somewhat like neuropathy, you don't want to be able to self-diagnose it: you want to prevent it before it becomes noticeable, which is awfully close in many patients to the point of also being irreversible. Diabetic neuropathies tend to be easier and cheaper to diagnose currently and don't need a specialist (and could probably be done by patients themselves with monofilament examinations). The same isn't true for the eyeballs —yet.

Comment Re:Thank you Democrats? (Score 3, Informative) 326

Good intentions, maybe, and despite the grief there are some advantages. I can see my patient's clinic charts in the hospital - before, I'd have to wait for Monday and a fax machine. I can see what happened to folks in the emergency department. I can figure out my obstetric patients' prior pregnancy history. I can send records to specialists directly, and send requests with an electronic copy of a chart note and pictures of moles and whatnot at no cost to a patient and sometimes save them a visit to another office.

It's not perfect, but it's not a total disaster either.

Comment Re:Burnt out doc here: (Score 2) 326

I like a conspiracy theory as much as anyone, but I really don't think the NSA convinced Congress to pass the not thoroughly thought out HITECH Act to amass statistics about the home addresses of people with pneumonia or which patients with high blood pressure are smoking. Being able to gather anonymized statistics on public health issues may help, however, to figure out how to improve immunization rates or best help diabetics get their blood sugar under control.

To the grandparent poster, our EMR company actually will pay their own way to have their engineers follow us around and see how we work, and our prior vendor was originally a nice internist who wrote his own code (who then sold the thing to a big conglomerate that also makes microwave ovens and jet engines and curling irons and stuff).

Our current EMR does a lot of stuff well, but I'm hopeful for the day it's more usable by clinicians. The basic process of writing progress notes (in some sense, the evidence of my life's work as a physician) is clunky and hard to correct and even less intuitive for my colleagues who don't happen to have fancy computer science degrees like me. Writing good software is hard, and maybe progress notes have had to wait in line behind revenue cycle and privacy and a bunch of compliance issues.

Comment Re:Uneasy About Starting Without a Physician (Score 1) 301

As a physician practicing in a US state (Oregon) where oral contraceptive pills are available behind the counter, I'm all for expanding access to contraception. Nothing quite has made otherwise young, promising women be overwhelmed in my practice than unplanned pregnancy (combined with flaky partners). OCP's are available here without a prescription, but require a consultation from a pharmacist. This isn't free, but where they make sure you don't have any of the various risk factors for having a stroke or blood clot on estrogen-containing contraceptives.

I'm also in favor of expanding access to more effective forms of contraception, like the subdermal implant (sold as Nexplanon in the US), and IUD. I'm pretty puzzled, however, about how one would implement an app to jab the implant in your arm. It's not hard to do (see this video), but clinicians have to get special certification from the manufacturer to do it. (This is to avoid the Norplant debacle of inadequately trained people putting the rods in a little too deep, making eventual removal challenging.) I do love the idea of having etonorgestrel rods and lidocaine hooked up to a smartphone app, however.

Comment Re:War Story on Medical System Security (Score 2) 85

Epic is a big suite of applications that run on top of a big iron server - typically Unix (ours is AIX, I think). There's fine-grained user permissions in the application itself. End users do not have shell access or filesystem access or MUMPS prompt access, and everything has an audit trail. A select group of IT nerds get access to a text-based system running as a (Unix) application (with audit trails), and, at least at our organization, next to no one gets MUMPS prompt access or shell access. We have hot swappable servers located on opposing coasts of North America. I can't speak to the implementation at your daughter's site.

There may be examples out of there of hackers breaking into Epic; I'm not aware of any. Since our implementation was modeled after Epic's recommendations my impression is they've got their heads screwed on straight, security-wise.

Comment Re:There might be a problem with... (Score 1) 265

Good luck getting EMR applications disconnected from the Internet. Every institution I know of has their EMR available behind a firewall, accessible visa Citrix. So we can work on our charts after putting the kids to bed (not uncommon for that to be a 1-2 hour task) and covering our partners during overnight call and answering emergency calls when out of town. And for seeing patients in nursing homes, and home visits (they still happen!). And our EMR's exchange information with one another, so if you go to hospital X in my town and then show up in office Y to follow up with your regular provider we can tell what happened Or, I dunno, I suppose you could keep us (physicians) locked up in the office for 24 hours 2-3 days a week and for 14 hours (instead of 12) on non-call days. I know, boo hoo hoo, but I think this horse has left the barn.

Comment Re:Document2 (Score 1) 265

When I worked as a software engineer, typed my password in for various ssh sessions maybe 10 times a day. Now that I'm working as a physician, every time I walk in and out of a patient room (which can be multiple times for visit, fetching the liquid nitrogen and scalpes and where are we keeping the extra large speculum this week anyway). I get to type in my (Active Directory) password with its enforced mixed capitals and numbers that I'm not allowed to change (too many disparate systems, apparently), maybe 50 times a day.

Which doesn't help with the spear-phishing, right? That just requires that I click on the link in the email addressed from my information security department, complete with their logo, saying they need to verify my information. I don't think my clinician colleagues are falling for that much, but the folks who answer the phone, hired out of high school, it's easy enough for them to fall for it.

Comment Re:Never mind his face, I don't like him. (Score 3, Insightful) 203

Or it means you had diabetes (and there are plenty of thin, otherwise people with diabetes) and didn't work for a company that offered health insurance;

Or it means you had a (now illegal) plan that "covered" well child visits, just not more than 2 in the first two years of life (out of the 9 that are the standard of care);

Or it means you fell off a ladder painting your house and broke your back;

Or it means you have congenital heart disease —

SORRY SUCKERS! You shouldn't have had Pacific Islander grandparents/been a kid/painted your house/been born — not my problem! I'm not saying "Your problem, not mine" isn't a valid viewpoint, but I do think that letting people who have treatable medical problems through no fault of their own drop dead in the streets is a bit more individualistic than all but the most libertarian viewpoints in the US. Not to mention every single other developed nation on the planet, that somehow manage to have popular support for their universal health care systems yet still spend about half of what we do.

Comment Re:Under supervision (Score 1) 82

I am interested in this 1 and 1.5 year time for PA and MD programs. Our local PA school provides a 26 month course (done in just over two years), and MD school is 46 months (done in 4 years, but you get two summer breaks the first two years). But at the end of MD school, the shortest available residency is still 3 years (of about 80 hours a week with little vacation), whereas the PA education pathway is not typically associated with residency programs. Those are growing, but are still typically a year long.

I suppose autonomous robot surgeons may arrive someday, but it's hard to believe that day would arrive any time soon. Getting your Google car to avoid knocking over granny in the crosswalk is one thing, but getting a baby with a typically soft skull wedged out of the pelvis during a C-section or figuring out where the heck the bleeding is coming from from a sheared artery somewhere deep inside with no time to spare —that seems well beyond our current robotic capabilities.

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