Saturday, August 31, 2013

The UPSETTER - Life and Music Of Lee Scratch Perry

Undeniably one of the most important forces in music. 

First to put a sample on a record.
First to scratch on a record. 
 First Reggae.
First Dub.

Friday, August 30, 2013

Do Physicians Spend Too Much Time With Computers?

A recent study of work hours of medical interns in the new era of duty hour regulations produced an interesting side finding, which is that modern medical interns spend about 40% of their time at a computer [1]. To some, this prompted concern that computers were drawing medical trainees away from patients and their care.

A finding like this certainly warrants attention. However, I wonder whether many expressing concern are asking the wrong question. The proper question is not whether this is too much time at a computer, but rather if this amount of time compromises the interns' care of their patients or of their learning experience.

Implicit among those who raise the question of too much time with computers is the assumption that computers are taking physicians away from patients. It is instructive, however, to consider historic data of how much time physicians spend in direct vs. indirect care of patients. It turns out that physicians have historically spent most of their working time in activities other than in the presence of their patients.

Time studies of hospital [2-6] and emergency [7] physicians show physicians spend about 15-38% of their time in direct patient care versus 50-67% of their time in indirect patient care, divided among reviewing results, performing documentation, and engaging in communication. Likewise, studies of outpatient physicians find that 14-39% of work takes place outside the exam room [8-9]. In addition, work related to patients when they are not even present at the hospital or office consumes 15-23% of the physician work day [9-11].

Therefore, this new study does not necessarily indicate the computers are drawing physicians away from patients. It is difficult to compare the proportions of these interns' time devoted to direct and indirect care with those of other physicians who have completed their training. However, it is worthy to note that the four-fold ratio of indirect to direct care is not too far off what was document for practicing physicians in the other studies. Interns have different time demands anyways, not only working longer hours but also devoting more time to educational activities.

Furthermore, we also have to consider the premise that there good reason for spending more time in front of computers, as some evidence supports the notion that there may be value to patients as well as clinician education in having access to knowledge in unprecedented ways that previous generations of physicians did not have [12-13]. There is no question that we must pay more attention to physician workflow with computers so that they are not unduly wasting time, especially time that could be better spent with patients. But we must also consider the benefits of computers, and try to determine the most appropriate amount of time for physicians to spend using them during their working hours.


1. Block, L, Habicht, R, et al. (2013). In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? Journal of General Internal Medicine. 28: 1042-1047.
2. Ammenwerth, E and Spötl, HP (2009). The time needed for clinical documentation versus direct patient care. A work-sampling analysis of physicians' activities. Methods of Information in Medicine. 48: 84-91.
3. Tipping, MD, Forth, VE, et al. (2010). Systematic review of time studies evaluating physicians in the hospital setting. Journal of Hospital Medicine. 5: 353-359.
4. Tipping, MD, Forth, VE, et al. (2010). Where did the day go?--a time-motion study of hospitalists. Journal of Hospital Medicine. 5: 323-328.
5. Kim, CS, Lovejoy, W, et al. (2010). Hospitalist time usage and cyclicality: opportunities to improve efficiency. Journal of Hospital Medicine. 5: 329-334.
6. Yousefi, V (2011). How Canadian hospitalists spend their time - a work-sampling study within a hospital medicine program in Ontario. Journal of Clinical Outcomes Management. 18: 159-164.
7. Chisholm, CD, Weaver, CS, et al. (2011). A task analysis of emergency physician activities in academic and community settings. Annals of Emergency Medicine. 18: 117-122.
8. Gilchrist, V, McCord, G, et al. (2005). Physician activities during time out of the examination room. Annals of Family Medicine. 3: 494-499.
9. Gottschalk, A and Flocke, SA (2005). Time spent in face-to-face patient care and work outside the examination room. Annals of Family Medicine. 3: 488-493.
10, Farber, J, Siu, A, et al. (2007). How much time do physicians spend providing care outside of office visits? Annals of Internal Medicine. 147: 693-698.
11. Chen, MA, Hollenberg, JP, et al. (2010). Patient care outside of office visits: a primary care physician time study. Journal of General Internal Medicine. 26: 58-63.
12. Buntin, MB, Burke, MF, et al. (2011). The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Affairs. 30: 464-471.
13. McCoy, AB, Wright, A, et al. (2013). State of the art in clinical informatics: evidence and examples. Yearbook of Medical Informatics. 8: 13-19.

Thursday, August 29, 2013

Retro Hi-Fi Girl Friday

Three girls rock'n out.

Unity Farm Keets (Guinea Fowl chicks) Available Now

Our Guineas have been remarkably fertile this Summer and we'll have 100 babies available for purchase.   They're $4 each.

Guineas are tick eaters and will rid your yard of many undesirable insects.   You will need a coop to keep them safe from predators at night.

Our first hatching of 20 is extremely healthy and we'll have another 30 hatching this weekend.

Although chicks are shipped in general, our experience is that the process is extremely stressful for them.    Anyone wanting guineas should contact us at for New England (Sherborn, MA) pick-up.  Here are the details:

Straight Run (M/F) Hatched 8/20/2013
Pearl Gray (standard dark color)
Pearl Gray Pied (white chest)

Colors possible (Pearl Gray, Pearl Gray Pied, White, Lavender and Lavender Pied)
2nd Hatch on 9/3/2012
3rd Hatch (last for the year) on 9/18/2013
All will be well feathered by the time cold weather arrives

$4 each or 10/$30

Comback For Corner Horns - Installation Of The Month 1962

Nice EV home built Georgian corner horns. Different from the Klipschorn in that this has a 15 inch in the bass bin but 8" midranger and a horn tweeter. Powered by Eico kits and Rek-O-Kut.

National Nutrition Week

Ms.Rohini,Sheela Paul-    Dietitian

National Nutrition Week is celebrated from September 1 to 7 every year.  Good nutrition is the focal point of health and well-being. In other words, it allows you to be strong, provides energy to do the things you want to do, and makes you look and feel good.

Food groups

Most of us know that the basic food groups are cereals

Wednesday, August 28, 2013

The EHR Tipping point, HEDIS® Uncertainty Principle and the Hypoplastic Hypothesis

(From time to time, the Disease Management Care Blog welcomes commentary from its readers.  Here's an interesting thought.....)

As a long-term reader, I thought the erudite but contrarian and sometimes snarky DMCB might be the best venue to ask others of my ilk to comment on an observation of mine.

I am a primary care provider working at the quantum level of patient care.  I am in my second year of full fledged EHR use.  It is obvious to me from the consultation notes that I receive on an hourly basis that most of my colleagues are also on board.  Journal articles as well as my first-hand experience have convinced me that we have indeed reached the tipping point of electronic record use. 

Since this milestone passed, I have noticed a change in the focus of office notes and consults.  I am seeing neurosurgeons document conversations regarding the safety of patients relationships and whether or not they feel threatened.  Podiatrists routinely document the existence of living wills.  Dermatologists are now savvy about the sexual activity of octogenarians with actinic keratosis. Despite my consultants' thoroughness in their care (and conversations with health care students who have rotated through these specialties make me believe that some specialists are using telepathy to document things), I am not seeing traditional assessment and plans at the end of the encounter. 

What I usually see is the same generalized diagnosis code that I sent them with followed by a list of tests cluttered with a references to various quality metrics that are inspired by systems such as HEDIS®.  The old fashioned differential diagnoses or thoughtful prose concerning the evaluation is conspicuously absent. 

I call this my hypoplastic hypothesis.

As a primary care physician, when I consult a colleague, I am really asking the specialist “Hey, what do you think?” Prior to the advent of the EHR, much of my continuing medical education has come from the insights that I use to get from these consults. Now I'm reading about feeling threatened, living wills and sexual activity.
How did we get here?

When I was an undergrad in Biochemistry, during the dreaded Physical Chemistry course, we learned about the observer effect and the Heisenberg uncertainty principle. Wikipedia defines both as:

"In science, the term observer effect refers to changes that the act of observation will make on a phenomenon being observed. This is often the result of instruments that, by necessity, alter the state of what they measure in some manner. A commonplace example is checking the pressure in an automobile tire; this is difficult to do without letting out some of the air, thus changing the pressure. This effect can be observed in many domains of physics.....However in quantum mechanics, which deals with very small objects, it is not possible to observe a system without changing the system, so the observer must be considered part of the system being observed.

In quantum mechanics, the uncertainty principle is any of a variety of mathematical inequalities asserting a fundamental limit to the precision with which certain pairs of physical properties of a particle known as complementary variables, such as position and momentum, can be known simultaneously. For instance, the more precisely the position of some particle is determined, the less precisely its momentum can be known, and vice versa."

In my opinion we now have a new phenomena that parallel the laws of physical chemistry:  I call it the HEDIS uncertainty principle

The actual act of measuring HEDIS® scores and other similarly contrived quality metrics has fundamentally intruded into the quantum level of physician care.  Does this measurement change the behavior of the particles of the system and alter the ultimate structure of the encounter?  Are the data still reliable and the measurements still accurate?  Have the impressions and treatment recommendations indeed become hypoplastic, or has the encounter remained unchanged but the documentation is skewed to HEDIS®? Is the question asked of the consultant answered but not documented?  If not, what does this portend for disease management and health care quality?

I have my suspicions, but I would like to tap the wisdom of the DMCB readers for theirs.

Image from Wikipedia

Early Lansing Factory

This is a great pic of the early Lansing factory and multicell horn construction. That 10 cell multicell horn looks big.  I've always wanted to see a modern take on the multicell perhaps with tractrix or le cleach profiles for each cell. However construction looks difficult.

Tuesday, August 27, 2013

LOUDSPEAKERS A Visual Hi-Fi History 1870 - 2008

Cool poster of HiFi history. They left out a few though... LOL

I don't have a larger version of this.
But everyone else knew about this site.
You can order HiFi posters from 
Thanks for the heads up Peter and Joe.

Fee-for-Service Medicare Beneficiary Access to Care: The Truth May Be More Complicated

According to this just-released Health and Human Services Issue Brief, the percent of U.S. physicians "accepting new Medicare patients" increased from 87.9% in 2005 to 90.7% in 2012. What's more, this rate of uptake of new Medicare beneficiaries is tracking higher than the rate of "new privately insured patients."

The Issue also says there "may" have been a "very small increase" in the number of docs who have dropped out of the Medicare program. Those drop-outs appear to be greatest among psychiatrists (1.1%) and plastic surgeons (1.6%). In contrast, only 0.35% of primary care physicians have dropped out. These drop-outs have been more than compensated for by the new physicians entering the labor market.

Except for 2012, these data are from the in person interviews that comprise the National Ambulatory Medical Care Survey, The 2012 numbers are described as "interim," because they are based on a mail-in survey.

The Issue brief also quotes a separate MedPAC annual survey of thousands of Medicare beneficiaries. According to the brief, 77% reported they never experienced a delay in getting an appointment for routine care, compared with 76% in 2008.

Case closed, right?  The Disease Management Care Blog's dire warnings about a widespread provider exit from Medicare that was echoed years later by the Wall Street Journal have been overblown.

Not exactly, speculates the DMCB, for the following reasons:

1. The DMCB pulled a copy of the NAMCS survey and found the question that was apparently used to assess physician participation. The screen shot is above. It generically refers to "Medicare," not fee-for-service Medicare.  Because many physicians are members of insurance networks, an affirmative answer could be misinterpreted by the respondents as referring to Medicare Advantage. 

2. There is a difference between "accepting" new patients vs. welcoming new patients. In this seminal New England Journal study, many respondents "accepted" "new" Medicaid beneficiaries, but moved them to the back of the appointment queue.

That being said, the MedPAC survey suggests that isn't happening           - yet - to Medicare beneficiaries. And that's assuming a health care consumer's definition of "delay" hasn't been dumbed down since 2005.   

3. Last but not least, the NAMCS numbers represent a national average. Many areas of the country have seen consolidation of physician practices into larger groups. The DMCB suspects these entities are more willing to accommodate Medicare beneficiaries. It's very possible that the smaller physician-owned practices - many of whom practice in rural areas - are less likely to do so in 2013 than they were in 2008.


In yesterday's post, the DMCB was introduced to "twerking." After additional inquiries of the DMCB spawn, it has learned more about this curious phenomenon. 

Which led to this insight:

Q: What is one key similarity between twerking and being an ACO?

A: You better be careful doing both, otherwise you could get screwed.


Monday, August 26, 2013

Time for Docs to Get Out of the Food Wars

In Food Fad Fantasyland, rotund patients can see their primary care physicians and discuss the merits of Atkins versus South Beach vs. [insert name here].  Armed with the latest nostrums, patients go forth and diet until the next twerk comes along.


While physicians and the for-profit care management vendors can disagree about many things, one thing they can agree on is the ability of their corpulent patients to swear by an endless number of diets.  Whether its "low carbs" or "Mediterranean" or "mini-fasts," docs and coaches alike are expected to not only endorse these fads, but deploy insider jargon like DMCB spawn watching the MTV Video Music Awards. Taylor Swift was crooning about... who?

Which is why, after reading this JAMA Viewpoint article, the Disease Management Care Blog agrees that it's time call a time-out.  It's also time for the DMCB primary care colleagues to exit.

The DMCB explains.

Drs. Pagoto and Appelhans point out that when it comes to weight loss and risk factor reduction, there is no research that convincingly proves that one dietary approach is superior to any other.  Outside of individual preference, the mix of nutrients makes no real difference.  Instead, say the authors, what's important is adherence.  In other words, once patients embark on their preferred diet, they have to stick to it.

Unfortunately, that message has been lost in the multi-billion dollar faddism that has come to dominate the food industry marketplace.

Skeptics will point out that getting persons to stick to a particular diet is a fool's errand.

Not so, say the JAMA authors. Pointing to the Finnish Diabetes Prevention Study, The Da Qing Diabetes Prevention Study and the Diabetes Prevention Program, they note that long-term behavior change that includes behavioral modification and lifestyle change is very possible. 

"Hear hear!" says the DMCB.

As most doctors are aware, most health insurers (including Medicare) don't really reimburse enough to meaningfully cover the true costs of life-style related counseling.  What's more, selective memory recall means that physicians generally remember just how often their counseling leads to their individual patients being as fat as ever.  Most of us physicians are not that good at coaching anyway.

Which is why the DMCB thinks dietary counseling should be outsourced outside of the doctors' offices.  The good news is that wellness and health promotion programs are becoming more adept at focusing on patients' adherence to lifestyle change, mostly by finding those with a willingness to change. It's then a matter supporting those individuals over the course of a year or more. 

This is just one example of the approach.  There are more to come.

The DMCB conclusion

1. Docs should be "agnostic" when it comes to one diet fad vs. another.  It's patient preference.  Next.

2. What really counts is adherence to long-term lifestyle change.  Since many physicians are not good at that kind of long-term coaching, better to let other programs offer their wares to insurers.  The key for these programs is to focus on lifestyle change for those patients who want it and can accomplish it.

1938 RCA Radiotrons Ad

17 years of progress from 1921 to 1938. 
My tube hoarding friend just scooped some ham tubes with some nice 833a's in the batch. They remind me of Forbidden Planet for some reason.

Wednesday, August 21, 2013

Old Time Religion - Western Electric 16A

I never get tired of Western Electric 16A pics.
I wonder if that is Wente, Thuras, or Blattner in the pic.  Can't tell if the quad 555 drivers are mesh or standard but I'm guessing standard.

Another Large Scale Research Study Confirms the Value of the Approach of Population Health Management

And here's another study, this time published in JAMA about Kaiser in Northern California that found that the following five components resulted in an increase of population-based blood pressure control

1. "Registry" (which the Disease Management Care Blog says is really a stand-alone database that is outside of the electronic health record);

2. "Control Rates" (which the DMCB figures is really an updated "dashboard" that displays key metrics to administrators and docs that provides feedback and helps keep everyone on the same page);

3. "Guideline" (in reality, it was a campaign to gain provider buy-in consisting of emails, publications, pocket cards, conferences, lectures and decision support);

4. "Medical assistant" follow-up operating under protocol to adjust medications (a.k.a population-based care management)

5. "Single" pill treatment (in other words, keep it simple by using pharmaceuticals that are combined in a single once a day prescription pill).

DMCB readers will not be surprised to know that the registry showed a progressive improvement in BP control (defined as less than 140/90 with the usual HEDIS® caveats) from 43.6% in 2001 to 80.4% in 2009.  Because everyone with hypertension at Kaiser was in the registry, there is no internal comparison group.  However, national and northern California HEDIS® rates for blood pressure control ranged from 55.4% to 69.4%.

While the results are 1) not necessarily generalizable outside of integrated systems like Kaiser (so we don't know for sure that this would work in a network of primary care clinics in Idaho), and 2) may have been influenced by an influx of patients with mild and easy-to-treat hypertension during the campaign), the DMCB is impressed

An 80% control rate for hypertension is damn good

The DMCB also figures that each of the interventions above are mutually supportive and even synergistic.  The whole is much greater than the sum of its parts.

How to translate this kind of success to networks of independent practices?  The answer, says the DMCB, is population health management: sponsored programs that can be owned by an insurer or a provider network that synergistically identify a population, maintain a data base, create a virtuous cycle of measurement and adjustment, get the doctors on board, deploy care managers and are smart about the pharmacy benefit.

If your a PHM service provider, vendor, consultant or stakeholder, the DMCB suggests this is one of those research papers you should bookmark, quote and aspire to.

Image from Wikipedia

Tuesday, August 20, 2013

Klipsch Belle Wallflower Sister Of The Klipschorn

There were not very many Klipsch Belle speaker advertisements in print. These are the only two I could find.
The Klipsch Belle was my first HiFi speaker. This is my audio room right after moving many years ago. Klipsch Belle speakers, George Wright WLA12 preamp, Canary Audio CA-300 300B SET and some cd and turntable. This system was really good and in some ways I always try to get back to what this system did correctly. Now my room is covered in vinyl instead of CDs. Large two way horns bi-amped instead of store made system. It is really weird looking back.

Why The Tipping Point for Health System Consolidation May Be Closer Than We Realize: Lessons from Airline Mergers

Ready for take off
From time to time, the Disease Management Care Blog and other pundits turn to the airline industry draw lessons on the evolution of health careIntegrated human-computer systems, safety check-lists, website-based Expedia-like price transparency, teaming and other such notions have infiltrated health policy PowerPoint presentations worse than Doritos bags in Seattle Hempfest crowd.

While the DMCB was mulling another lesson about the divide between coach (what vanilla insurance could turn out to be) versus business/first class (concierge-style direct pay), along came this interesting Wall Street Journal article by airline industry bad boy Robert Crandall about the American Airlines - US Airways merger.  He argues 1) mergers that lead to bigger are better (no surprise there) and 2) if some airlines are allowed to go big, the only way for others to compete is to go bigger also.

That latter argument is important, and may also hold lessons for health care. 

Mr. Crandall argues that once the furies are released and one or two regionally dominant service providers are allowed to populate the marketplace, smaller competitors are at a disadvantage.  As a result, they have no choice but to also seek alliances and mergers.  How well government reconciles consumer interests and business profitability will remain an open question involving lawyers, bureaucrats and politicians.

Ditto regional health care systems, accountable care organizations and integrated provider organizations. 

Once one of these behemoths is unleashed in a city or corner of a state, smaller neighboring provider systems will naturally circle the wagons and seek permission to consolidate so that, just like the airlines, they can compete. They make a good argument, because without the size, they could go bankrupt. 

As health reform continues, geographically large systems that can access capital, achieve economies of scale, become accountable and take insurance risk will grow in number and complexity. That will only fuel the further consolidation of small local hospitals and smaller physician practices.

In other words, the lesson from the airlines may be that that "tipping point" for nationwide health system consolidation may be much closer than we realize.

Image from Wikipedia

Are You Ready For The Sound Apocalypse?

No not MP3's but this example of the coming mobile sound apocalypse.
Be prepared. 
Get slack.
I assumed there would be more horns in the apocalypse?

Monday, August 19, 2013

More on Penn State's Wellness Woes and The Evolving Science of Evaluating Health Promotion Program Outcomes: There Is No Gold Standard

Aside from keeping up to date with work buddies, the Disease Management Care Blog doesn't really use LinkedIn all that much. But when "Support our Penn State Colleagues in their Fight to Prevent Coercive Junk-Science Wellness Programs" postings began to appear in a Discussions board, the DMCB couldn't resist. It rose in support of its alma mater (College of Medicine, '77) faster than a med-mal attorney can calculate a contingency fee.

 As noted in this prior DMCB posting, Penn State University launched a rather routine health promotion program that prompted some nasty and very public teaching faculty resentment. Calls for "civil disobedience" and sinister references to "eugenics" made the DMCB wonder how much of the reported push-back was mainstream employee opinion vs. mainstream media's biased reporting. That distinction didn't stop the LinkedIn board from running a mostly one-sided dialogue on the matter.

So, undeterred by the unfairness of so many vs. just one, the contrarian DMCB naturally jumped right in.  Among the issues raised:

The RAND Study on wellness casts doubts on the merits of employer sponsored wellness programs:

Actually, RAND found employer-sponsored programs lead to statistically significant increases in exercise levels as well as reductions in tobacco abuse and body weight.  To the disappointment of wellness vendors everywhere, however, these programs did not lead to statistically significant reductions in health insurance claims expense.  The ever-optimistic DMCB points out that that means that these health improvements occurred without an increase in health care costs.

While cost neutrality alone is good news, the DMCB also believes that an emerging generation of wellness programs will do a far better job of identifying persons with 1) actionable risk and 2) who are willing to take action.  By husbanding wellness resources for subpopulations where it will have the greatest "bang," program costs will go down and claims savings will achieve statistical significance.

The author of the widely quoted Health Affairs paper on the merits of employer sponsored wellness programs has back-pedaled away ("too early to tell") from her study's original conclusions.

Actually, the original Health Affairs paper said that the finding of a $3.27 return on every dollar spent is subject to:

 "(f)urther study.... to elucidate the time path of return on investment.... The assumption of a linear trend in savings from the beginning to the end of program evaluation may not reflect the reality of behavior change within organizations."

The point is that nuanced and calibrated conservatism is typical of excellent peer-reviewed research and, taken in context, the authors are being quite consistent in-print and on-air.  Academics will always say more research is needed.  Skeptics will over read that.

There are powerful arguments against the common wisdom that "wellness saves money," suggesting that the health promotion industry has been intentionally ripping employers off.

Actually, when it comes to wellness outcomes, there is no agreement on "the" measurement "gold standard." Without any consensus on which assessment approach (for e.g., this vs. this) is truly "better," only one thing is certain: much like the Betamax vs. VHS wars, the future owner of "the" standard stands to reap a consultant's bonanza. Until we declare a winner, assessing the truth will be a messy mix of triangulating on means, medians, confidence intervals, imperfect reference controls, suspect generalizability, human judgment, moving targets and evolving interventions.

What about [insert name of wellness program here] that is an obvious sham?

There have been women who have had mammograms with missed cancer, victims of car crashes who have died despite seat belts and times when the DMCB did something really dumb despite the advice of the DMCB spouse.  That doesn't mean mammogram, seat belts or advice are worthless.  The plural of anecdotes is not data.

Coda: By the way, the statistically significant "value of  0.05" is more of a consensus than a gold standard.  Why is a 5% chance that an observed result is not the result of randomness wiser than a 6% chance or a 4% chance?

Sunday, August 18, 2013

Edgarhorn 50

Edgarhorn 50

I have been scouring the internet looking for more info on these Edgarhorns but can not find very much. Does anyone have anything they can share about these?

 Interesting two way horn system. Beautiful.

ACGME Releases Draft Clinical Informatics Fellowship Program Requirements For Public Comment

As with all medical subspecialties, the new clinical informatics (CI) subspecialty will need to develop fellowship training programs for those seeking to enter the field. After the first five years of the subspecialty (which starts in 2013), during which the training requirements to be eligible to sit for the certification exam can be met by the "practice pathway" or a “non-traditional fellowship" (i.e., "grandfathering"), starting in 2018 the only way to become certified will be through a fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).

On July 29, 2013, the ACGME released a draft program requirements document and opened up a 45-day comment period for public feedback (with comments due September 11, 2013). This posting provides a summary of the 26-page document. In a subsequent post, I will provide the comments that the Oregon Health & Science University (OHSU) biomedical informatics program submits to ACGME.

As with most training requirements documents, there is boilerplate (required of all specialties, in bold text style) and specialty-specific text (plain text style).

All CI programs will need to be administratively integrated with one of six specialties: Anesthesiology, Emergency Medicine, Medical Genetics, Pathology, Pediatrics, or Preventive Medicine. This does not mean that a program needs to be focused in one of these specialties; it only means that it must be administered by one of them. CI programs will not have their own residency review committees (RRCs), but instead will be reviewed by RRCs from these six specialties. Physicians from other specialties can enroll in any of these programs.

Programs will be required to be of 24 months duration, with the fellow having completed the program within 48 months.

There must be a single program director who is board-certified in CI or a subspecialty acceptable to the RRC. There are substantial administrative responsibilities for the director. He or she must also have five years experience working in CI. There must be two additional faculty members, with the three faculty collectively devoting at least two FTE to administration, supervision, and teaching. There must also be a program coordinator to provide administrative support.

In addition to resources for education, the program must have a "clinical information system" that contains health and wellness data, includes clinical decision support, and is accessible in all (inpatient and outpatient) healthcare settings.

The program must of course have an educational program that has clear competency-based goals that are distributed to faculty and fellows at least annually. There must be regularly scheduled didactic sessions. The document is not specific as to the content of the educational program, but of course the content must as a minimum prepare the student to pass the CI subspecialty board exam.

The educational competencies that the program must follow are based on the six ACGME core competencies, with some additional learning objectives specific to CI. The ACGME competencies and some of CI extensions include:
  1. Patient care and procedural skills – leverage information and communication technology across the dimensions of healthcare to improve processes and outcomes
  2. Medical knowledge – demonstrate knowledge of informatics theory and practice
  3. Practice-based learning and improvement – develop skills and habits for self-evaluation and life-long learning
  4. Interpersonal and communication skills – communicate effectively, including serving as a liaison between information technology professionals, administrators, and clinicians
  5. Professionalism – demonstrate all aspects of professionalism, including the ability to recognize the causes and consequences of security breaches and to show sensitivity to the impact of information system changes
  6. Systems-based practice – in addition to understanding the operations of the healthcare system, be able to recognize and disclose the role of oneself and systems in medical error as well as identify and improve the impact of systems on clinical care
Programs must be evaluated at the level of the fellow, the faculty, and the whole program, to be done via:
  • Clinical Competency Committee of three program faculty to evaluate fellows semi-annually
  • Faculty evaluations to be done at least annually
  • Program Evaluation Committee of two faculty and one fellow for ongoing evaluation of program
In addition, the document states standard requirements for duty hours, supervision, moonlighting, mandatory time free of duty, and maximum duty period length. Clinical work may be performed in the fellow’s primary specialty.

(Thanks to Ben Munger of University of Arizona for reviewing this summary and providing feedback. All errors, however, are my responsibility.)

Thursday, August 15, 2013

Foods that heal …

Ivy Gourd (tendli, tindora, kovakkai)

It is seen throughout the year on shelves in vegetable shops and is classified as an herb in Thai and Ayurvedic medicine. Ivy gourd contains beta carotene – a good source of Vit. A that is good for the eyesight,  and Vit. C which protects from cold and flu. Consuming it can help regulate blood glucose. Some research also supports its use as an antioxidant

Wednesday, August 14, 2013

Penn State's Wellness Woes: Seven Lessons Learned About Launching a Worksite Employer-Based Health Promotion Program

Penn State's mascot goes on the
prowl for a good wellness program
Listen to this NPR report and it's easy to conclude that another employer-based health promotion program has gone amok. Reporter Jeff Brady implies rising health care costs have led Penn State University to force its employees into an intrusive wellness initiative, pitting David-like faculty members against the Goliath-Administration.

What can wellness architects and service providers learn from this imbroglio?

Here's the facts:

Penn State provides health benefits to over 45,000 employees and dependents. It's self-insured (administered by Highmark), which means the University, not some remote insurer, is on the hook for any unanticipated health care costs. 

Those costs have led to a whopping $217 million health care budget for 2013-2014 and a long term $3 billion pension liability. In response to the threat of budgetary "crowd out," the University made some important changes to the insurance benefit that included a high deductible option and value-based benefits.

It also hatched a health promotion initiative. It checked in with the Faculty Benefits Committee in the early spring of 2013 and then used the summer to unveil a "comprehensive wellness-focused strategy."  This included the "Take Care of Your Health" program that packaged biometric screening (some labs, weight blood pressure), an on-line WebMD wellness survey and preventive health exam. Failure to complete that screening, survey and exam will result in a $100 per month payroll deduction in 2014.

The plan didn't sit well with everyone. Faculty members Matthew Woessner fretted about privacy and penned a "call for action and civil resistance," Barry Ickes doubted the economics and Larry Backer invoked eugenics, human dignity and sinister profit-motives.  Brian Curran used the Change.Org website to post an anti-wellness petition for "employees, alumni and friends" that has reached 2000 signatories.  Naturally, wellness gadflies Vik Khanna and Al Lewis were unable to resist and used The Health Care Blog to pile on any wellness program with the temerity to not use their consulting services.

The Disease Management Care Blog speculates on lessons learned......

  • While worksite wellness programs have a reputation for increasing employee morale, it stands to reason for that any stressed organization (and here's why that may be true here), it runs both ways: low employee morale can hinder acceptance of a wellness program. The faculty backlash may be as much of a symptom as a problem.

  • Lesson: Health promotion programs should tread lightly in times of organization turmoil.  This is no time for "big bang" multidimensional interventions, especially if they involve a $100 per month penalty.

  • There is good evidence that employer-sponsored wellness programs save money, but it's unlikely that any health promotion will be enough to tame a $217 million budget.  To Penn State's credit, they simultaneously made some health insurance benefit changes, but that's been lost in this controversy.

  • Lesson: If you're fighting high health care cost trends, don't let the positive return on investment (ROI) from health promotion take the lead. It won't work that well, and employees will think this about reducing your costs, not about increasing their well-being.

  • Similar on-line WebMD wellness assessments for Pittsburgh city employees and the Mennonite Church have gone without any substantial privacy concerns.

  • Lesson: If there are two employee groups with a special talent for indignant paranoiac outrage over any employer-sponsored health initiative, it's medical providers and university faculty. There are plenty of reasons, but the DMCB suspects both are victims of the decades-long twin cultures of 1) autonomy and 2) abundance in health care and higher education.  Stopping by a Faculty Benefits Committee is not enough to secure buy-in.

  • Interestingly, Penn State's College of Medicine has a long standing agreement with Highmark that includes the joint development of evidence-based health, wellness and prevention programs.  Unless that's been cancelled, the medical science faculty's silence is deafening.

    Lesson: Search for and engage employee subgroups that can be your allies in launching a health promotion initiative. Their advocacy may really help.

  • There are wellness service providers like this and this with established records of performance that can successfully reconcile employee and employer needs.

  • Lesson: There's nothing wrong with preferring to "build" over "buy," but only if both options are carefully considered at the outset.  External wellness providers are often subject to financial performance and recruitment standards. If the petition gains traction, the latter would sure come in handy here.

  • Critics of wellness programs in general and this one in particular say that they lead to unnecessary testing.

  • Lesson: The science is still evolving, but here is one answer to that criticism: it's not wellness per se but our society's love of technology.  Wellness programs can use initiatives like Choosing Wisely to develop even better programs.

  • As a self-insured entity, Penn State technically already has access to all the employees' insurance and claims information.  The WebMD privacy concern is silly.

  • Lesson: Now would not be a good time for Penn State's administration to point that out.


    The Authentic Klipschorn - A Voice With Perfection For The Sound Perfectionist

    This Klipschorn brochure is from 1953. Definitely one of the earlier ones.

    Tuesday, August 13, 2013

    Suggestions for Managing Health Reform in 2014

    Unfortunately for Mr. Obama, the spotlight on the some of the more unsavory aspects of the NSA's surveillance programs has forced him to call for "changes." In doing so, he turned to every rhetorical trick at his command, including minimizing Snowden's role, obfuscating the original intentions of the Patriot Act's authors and countering with largely cosmetic tweaks.

    Good thing that Obamacare has avoided a similar fate. Despite similar levels of public skepticism further compounded by the steady drip of implementation delays with other unintended consequences, the President can hang tough by resisting any and all statutory changes to the Affordable Care Act. Signaling any willingness to alter the legislation could embolden his foes, dismay his allies and prompt countless poison pill amendments.

    The obvious political calculus:  silence, veto threats and burying any changes in web site legalese.

    Yet, the ever-prepared Disease Management Care Blog wants to help.  In the unlikely event that Mr. Obama has to compromise on health care reform without really compromising, it offers up this teleprompter-ready statement that incorporates condescension, selected truths and confusion:

    "Despite my calls for bipartisan dialogue on how to further vilify fat-cat insurance executives, the debate on how to best implement Obamacare has proceeded in a not-always civil way. Like the DMCB's mother, I'm not angry, I'm disappointed. [applause] 

    While I'm annoyed at the failure of my supporters and opponents to grasp the obvious, I'm also reassured that 20% of our nation's GDP is being expertly managed by our superbly trained White House health economists. [applause]  You should be too.  [applause]

    I also know that continued unmanaged debate could complicate health care reform faster than one of my lawyer-friends suing an ACO for withholding care. That's why, effective today, I'm changing the subject by announcing that I will meet with hand-picked members of Congress.  I'll seek to improve the public's confidence in Obamacare by creating legislation that establishes the Commission of Official Managerial Assessment (COMA).  This will be a special office within the IRS. This expert commission will monitor, report, assess, analyze, examine, subpoena, audit, interpret, leak, manage, spin and regulate key aspects of Affordable Care Act's implementation.

    Image from Wikipedia

    Vitavox Type GP 1 Pressure Unit

    From Vitavox we have the Type GP 1 Pressure Unit. Or General Purpose 1.... Does that mean that SP  1 is Special Purpose 1? Those familiar with the movie The Jerk will get a chuckle.

    Sadly I don't have the next page.

    1967 Drimble Wedge & The Vegetations

    Cook and Moore at their best. Drimble Wedge & The Vegetations in swinging London.... 1967 London is stop #2 when I get the time machine.

    Monday, August 12, 2013

    Should Patients in Population Health Management Programs Have Access to Lay Care Coaches?

    Based on prior posts like this, the Disease Management Care Blog thinks the answer is yes

    That being said, this hot-off-the-presses research paper shows just much we need to learn about this emerging approach to the care of persons with chronic conditions like diabetes, high blood pressure and chronic heart failure.

    Lay Persons Educating Persons With Chronic Conditions in Primary Care Clinics

    The paper was just published in the Annals of Internal Medicine. It was a one year randomized study involving the patients at six Allina Health primary care clinics. 

    Twelve lay "care guides" had at least 2 years of college education and "strong interpersonal skills." They received two weeks of education that included setting goals, identifying and overcoming care barriers, behavior change techniques, the limits of scope of practice and how to use the electronic records to message physicians.  It was up to the care guides and the patients to decide on how often they needed to meet in face or by telephone. The guides were supervised by two RNs.

    Active (i.e. seen in the clinics within 6 months) patients who agreed to be in the study with high blood pressure, diabetes or heart failure were allocated in a 2:1 ratio to either a "care guide" or usual care. Goals were proscribed and were the usual HEDIS-style outcomes, such as achieving blood pressure control, reaching an A1c level, getting an echocardiogram, being on beta-blocker medications or getting a pneumovax immunization.
    The study was not "blinded," in that they and their providers were aware of the assignment. Recruitment began in July of 2010 and the study was completed in April of 2012. 6168 patients were screened, 2135 patients agreed to participate and 1423 and 702 completed the study from the care guide and usual care study arms.


    One year later, 82.6% of the care guide patients achieved their selected care goals vs. 79.1% of the usual care patients. That 3.5% increase was statistically significant.

    Most of that improvement was accounted by a higher rates of tobacco cessation, pneumovax immunization, getting persons with diabetes to get an eye exam as well as urine protein testing, and getting persons with heart failure to go through an echocardiogram.  There were no statistically significant impacts on blood pressure control, diabetes control, cholesterol control or medication prescribing.

    The care guides interacted with their patients on average 7 times (2 face-to-face and 5 by telephone).  They messaged physicians an average of 4 times.  There was no difference between the two groups in primary care office visits. Estimated cost was $286 per patient per year.

    The Disease Management Care Blog's take:

    There is increasing interest in incorporating lay-persons in the outpatient care of persons with chronic conditions.  That makes sense, because much of the educational "payload" may be deliverable using far cheaper and more engaging "peer" members of the community who - literally - speak the patients' language.  This is a nicely done randomized clinical trial done in a real world setting that adds to our understanding of this care option. The bottom line is that this study showed that the care guides had a real impact.

    When the DMCB looks at the actual numbers, it is also clear that the study had an uphill climb.  Many of the baseline measures of blood pressure, diabetes and heart failure quality relatively high to begin with. The impact of the care guides may have been much greater in a population with a lower baseline (such as in this study) with more "room" to move.

    Problems to think about for the next study.....

    Not all outcomes are created equally: Unfortunately, this study was something of a disappointment because the improvements were spotty, relatively small and limited to lightweight "testing" outcomes vs. more -hard-to-achieve disease control outcomes.  It may one thing for a peer patient to talk a patient into a urine test or a heart scan, it's another getting a patient to take more pills.  That may take a professional educator, a pharmacist or nurse.

    What do the patients want: In addition, the goals were based on a one-size-fits-all HEDIS approach.  They were not adaptable, negotiable or subject to shared decision-making.  If that had been in the mix, patient engagement may have been an additional ingredient that could have pushed other outcome measures toward statistical significance.

    What do the docs think: The DMCB notes that provider office visits did not go down among the care guide patients compared to the usual care patients. This makes the DMCB wonder if there wasn't enough physician buy-in: if there had been higher trust in the care guides' ability to manage these patients, it would have been reflected in less need to see the patients for a separate appointment.

    Predictive modeling to the rescue: Finally, there is the problem of treating all chronic illness patients the same. Not all patients with high blood pressure, diabetes or heart failure are as susceptible to behavior change, and not all patients who engage in behavior change achieve better outcomes.  The trick is to use risk stratification to find the patients with the greatest chance at benefit.  This study may have benefited from a more focused approach.

    Sunday, August 11, 2013

    JansZen Electrostatics

    A local store has a few audio rarities in stock. These Janszen speakers are beautiful. I can't find them in any Janszen material. There is no model number but likely Z-something.  
    The grill clothe and trim look very cool. 

     This is what is in side a 12 inch woofer and two electrostatic panels. I was very surprised at the sound. They were very nice.
     These are Janszen Z-900's. The specs say 38hz-22,000hz +-1db which I find hard to believe. I really like the cabinets on these with a little repair and work they could be amazing. Each cabinet is two of the above speakers two sets of electrostatic panels and two twelve inch woofers. 

     The panels are rated 700hz - 30,000 hz. I'm going to have to grab a pair of these for testing.