News&Views

November 30, 2007

“Googling my own DNA”

Filed under: — mlazoff

In a recent New York Times report, My Genome, Myself: Seeking Clues in DNA, Amy Harmon continues her series on genetic technology by describing her personal reaction to genetic testing. “For as little as $1,000 and a saliva sample, customers will be able to learn what is known so far about how the billions of bits in their biological code shape who they are.” A side bar on the second page of the article gives a brief description and links to the three companies that currently provide genotyping. The Health and Human Service’s Personalized Health Care Initiative is introduced by Secretary Leavitt in last month’s report, Personalized Health Care: Opportunities, Pathways, Resources. “In the coming years, new gene-based knowledge, combined with the advent of health information technology, can make possible a new kind of medical care for Americans.”



September 28, 2007

Public-Private Disconnect?

Filed under: — mlazoff

Yesterday’s Slate article, Where’s My Free Wi-Fi? Why municipal wireless networks have been such a flop, describes the failure of many free citywide Wi-Fi systems, particularly those based on private/public partnerships in cities like Philadelphia and San Francisco. “The result, as this summer has made clear, has been telecom’s Bay of Pigs—a project the government wanted to happen but left to underqualified private parties to deliver…The deeper problem is economics… Private municipal wireless networks have to compete against competitors with better infrastructure who paid off their capital investments years ago…Today, the limited success stories come from towns that have actually treated Wi-Fi as a public calling. St. Cloud, Fla., a town of 28,000, has an entirely free wireless network. The network has its problems, such as dead spots, but also claims a 77 percent use rate among its citizens. Cities like St. Cloud understand the concept of a public service: something that’s free, or near-free, like the local swimming pool.” Ignacio Valdes, MD, creator of the wonderful open access software news blog LinuxMedNews, noted in today’s entry that the failure of several citywide Wi-Fi projects “may shed some light on the failings of RHIOs.”  (For example, see Requiem for an HIE Dream in last month’s News&Views.)



September 11, 2007

In memoriam

Filed under: — mlazoff

The Wall Street Journal’s Health Blog offers an off-topic but reflective page on the World Trade Center: Past and Planned.



August 13, 2007

Safe kids

Using A Computer Kiosk to Promote Child Safety: Results of a Randomized, Controlled Trial in an Urban Pediatric Emergency Department, from this month’s Pediatrics, studied the effects of computers on parental education regarding safety issues in children. The study used Johns Hopkins’ Safety in Seconds program delivered on a  computer kiosk set up in their pediatric emergency department’s waiting room. After answering a few questions on the computer about their beliefs regarding child safety, parents then received a personalized report with ”tailored, stage-based safety messages” on selected topics that was, according to the study’s outcome measures, better read and acted upon by parents as compared to a boilerplate report given to a control group of parents. The patient population in this study was drawn from a lower income urban population, so they may have less access to computers without conveniently located, specially programmed kiosks—and so less access to their health information benefits, particularly the computer’s abilty to easily customize patient education, as this study demonstrates.



August 2, 2007

Altered States

Filed under: — mlazoff

The current issue of Nature published a Letter by Nicholas Schiff, MD and colleagues from the Weill Cornell Medical College in New York, which documents the use of a relatively new technology, deep brain stimulation (DBS), to treat a patient with a disorder of consciousness. Behavioral improvement with thalamic stimulation after severe traumatic brain injury and accompanying news articles describe the case of a 38 yo patient with minimally conscious state (MCS), a condition similar to coma but with intermittent periods of arousal. The patient was chosen for DBS study because while he sustained traumatic cerebral cortex damage six years earlier, his other brain functions were thought to be relatively intact. Electrodes were implanted in the intralaminar nuclei of the central thalamus with the goal to stimulate the undamaged areas of the cortex. Within 2 days of stimulation the patient, who had been in MCS for six years, demonstrated increased arousal. After 2 months of post-op recovery without further stimulation, the patient was subjected to a six month, double blind alternating crossover study to study the effect of DBS on several primary and secondary outcome measures (including motor, communication, arousal, and feeding skills). When stimulated, the patient was able to name objects, make precise hand gestures on request, and chew food. Some functions demonstrated a carryover effect even after DBS was turned off, while other functions required continual stimulation.

DBS has been used experimentally in the past to treat Parkinson’s Disease and other movement disorders, epilepsy, obsessive-compulsive disorder and other psychiatric conditions. Last year, DBS was the subject of a Time Magazine article, How Deep Brain Stimulation Works



July 31, 2007

Federal sensors

According to a news release adopted for publication in yesterday’s ScienceDaily, the Department of Defense has awarded a grant to a group headed by The Center for Bioelectronics, Biosensors and Biochips (C3B) at South Carolina’s Clemson University to develop an implantable biochip, “the size of a grain of rice,” that will relay health information from a wounded soldier (or a civilian hurt in an accident). C3B’s director explains, “…first responders to the trauma scene could inject the biochip into the wounded victim and gather data almost immediately. The device has other long-term potential applications, such as monitoring astronauts’ vital signs during long-duration space flights and reading blood-sugar levels for diabetics…We now lose a large percentage of patients to bleeding, and getting vital information such as how much oxygen is in the tissue back to ER physicians and medical personnel can often mean the difference between life and death.

The biochip is estimated to be five years away from human trials. For more information on this potentially revolutionary technology, of which C3B’s in vivo biosensors work is just one example, see the US Department of Energy’s Virtual Poster Presensation on Biosensors and Biochips.



July 23, 2007

A microchip on one’s shoulder

Filed under: — mlazoff

Would Americans sacrifice their anonymity so that their medical information is always available in an emergency? An ABC News article published on their Web site over the weekend, “Chips: High Tech Aids or Tracking Tools?” discusses the pros and cons of implantable microchips with radio frequency identification (RFID) technology. The article describes the technology: “In design, the tag is simple: A medical-grade glass capsule holds a silicon computer chip, a copper antenna and a ‘capacitor’ that transmits data stored on the chip when prompted by an electromagnetic reader. Implantations are quick, relatively simple procedures. After a local anesthetic is administered, a large-gauge, hypodermic needle injects the chip under the skin on the back of the arm, midway between the elbow and the shoulder…The capsules can migrate around the body or bury themselves deep in the arm. When that happens, a sensor X-ray and monitors are needed to locate the chip, and a plastic surgeon must cut away scar tissue that forms around the chip.” Noninvasive tags such as MedicAlert bracelets, currently used by patients with serious allergies or conditions, can be lost even when they are used consistently by the patient.

The relatively lengthy article describes both the technology’s benefits and downsides: “John Halamka, an emergency physician at Beth Israel Deaconess Medical Center in Boston got chipped two years ago, ’so that if I was ever in an accident, and arrived unconscious or incoherent at an emergency ward, doctors could identify me and access my medical history quickly.’ (A chipped person’s medical profile can be continuously updated, since the information is stored on a database accessed via the Internet.) But it’s also clear to Halamka that there are consequences to having an implanted identifier. ‘My friends have commented to me that I’m ‘marked’ for life, that I’ve lost my anonymity. And to be honest, I think they’re right.’”

According to the article, VeriChip Corporation makes implantable microchips for humans; 515 hospitals have opted into its network, but only 100 have actually been equipped and trained to use the system. VeriChip is currently targeting high-risk patients to be tagged. Physicians can purchase a starter kit with 10 microchips and a reader for $1,400. Each patient could be charged $200, an out-of-pocket expense payable directly to the physician since chip implants are not currently covered by private or government insurance. VeriChip currently charges $20 a year for customers to store their blood type, allergies, medications, driver’s license data and living-will directives. For $80 a year, it will store the customer’s full medical history.

(As noted on its Web site but not in the article, Dr. Halamka—who is also Chief Information Officer of Harvard Medical School, Beth Israel Deaconess Medical Center, and Harvard Clinical Research Institute, in addition to Associate Professor of Emergency Medicine—has just joined VeriChip’s Medical Advisory Board.)



March 11, 2007

EMIssion highly improbable

Filed under: — mlazoff

The March issue of Mayo Clinic Proceedings published a trio of studies looking into potential electromagnetic interference (EMI) of mobile devices in health care. They found rare instances of interference from mobile devices involving implantable cardioverter defibrillators and electrocardiograms outside the hospital setting. Importantly, they found no interference using mobile devices within hospitals, although only a handful of mobile and medical devices were tested. The hospital tests were conducted by the same group who found in 2005 that older analog cell telephones produced the most interference when placed within 3 feet of (also generally older) medical devices. 

The issue’s editorial closes with a summary of current standards and suggestions for the future: “On its Web site (www.fda.gov/cdrh/emc/emc-in-hcf.html), the FDA’s recommendations are more or less generic statements that medical facilities should check their equipment, identify locations where EMI could be problematic (eg, operating rooms and intensive care units), and educate staff. On the basis of the results of the 3 reports in the current issue of Mayo Clinic Proceedings it would be appropriate for the FDA to take a more explicit stand that EMI is unlikely to occur in a hospital setting and that internal regulations in health care facilities should reflect that fact. Recommendations should also reiterate that the risk is not zero and that medical personnel should remain vigilant in order to detect and mitigate the uncommon occurrence of clinically relevant EMI of medical devices.”



January 2, 2007

Brailer on Health IT

Before the holidays, the former National Coordinator for Health IT David Brailer, MD, gave an interview for iHealthBeat, the news digest of the California HealthCare Foundation. The full interview, released today, is available as an audio file (excerpts above, downloadable mp3 file below) or a PDF transcript.

From the interview:

  • “I always told people that the battle over health IT adoption was over. It was just a matter of time. The real fight, and this one I don’t have such optimism about, is the fight over patient centricity, or patient control of their health care, and, therefore, control over their health care information…And that’s not so much a health IT battle. That is a battle over the heart and soul of who owns controls and who sets the priorities for the health care system.”
  • “I think we don’t have the right privacy and security regiment. The one that we have under HIPAA and state laws was created largely in a world that didn’t anticipate electronic information that was stored for, or by, or used on behalf of the patient…And I think the American public has been very clear that they want to see privacy protections in place before they’re really willing to jump into [electronic medical records].”
  • “…incentives for adoption [of health IT]. We had the one-year fix to the sustainable growth rate…which gave physicians a bonus for submitting quality data. That has no effect whatsoever on health IT adoption. So it’s time to come back to the question that we’ve put aside during the whole pay-for-performance discussion for three years about the market incentives and the policy incentives to bring us into full adoption of electronic records. I, as a very keen supporter of incentives, withheld my judgment on that during the pay-for-performance period. I think it has now had its chance, and it hasn’t been able to deliver a policy with the impact that I think convinces me that it’s going to help us with adoption, particularly among doctors in rural areas, in a safety net and even small practices.”
  • “Well, I think the change…comes from every place but Washington…in states and in the private sector…I see states moving quickly, and they will do more in 2007 to create a more fertile environment for health IT.”
  • “But I think the promise of personal health information being shared goes beyond a record. I’m particularly excited by remote monitoring, remote patient management; things where it’s not just a static database but where we’re monitoring someone in their home so they don’t have to be in a nursing home or where someone can be monitored in an ICU bed and a doctor doesn’t have to be present all the time but can be tele-present…That is the same concept of a personal set of health information that is centered around the person, but it probably doesn’t meet our definition of what we would call a PHR today. I view more convergence happening between that concept of the database and the streaming set of information, as we really ask the questions about what problems the PHR solves or what opportunities it creates. I think as we start thinking that way, we will come back to this set of functional tools that help us improve the patient role in health care, just like health information has helped us in traditional care delivery beyond the electronic health record — medication administration, reduced errors in inventory management, the way communication occurs, let alone computerized physician order entry. These things that are unheralded heroes of how IT does help are a broad bundle of change, and I think you’ll see that on the personal side as well.”
  • “I think there are two subdebates that will play out, so it creates kind of a two-by-two table with four outcomes. The first one is whether we will go beyond all of the lip service. The patient should be in control of the health care system, in control of their care. They should have information to make treatment choices. They should have information to make a choice about a doctor. They should have the information to be able to make tradeoffs when it comes to various outcomes. And I think this is quite pronounced as we start thinking about the genomic world, where you have so many genomic risks, like, you know, you might have heart disease in the future, or you may have breast cancer, or you may have memory loss. And you have to decide if you’re going to act on that 20 or 30 years in advance. This question about whether we are going to move beyond the promise and actually make the health care industry centered on that, which is profoundly disruptive to the established interests that rely upon a very high volume of hospitalizations, or bouncing patients around, and churning patients a lot because we can’t quite create integrate care processes around them, you know, that’s disruptive. And I think that’s a debate about how far the industry will come towards focusing on patient control and consumer choice. And so you could think about that as either happening or not.
           Secondly, and I think apart from that, there’s a debate about the role of government. We’re sitting in a hybrid system now. Government intrusion in private sector, or participation — neither one is dominant and neither one has the leverage to make it cohesive. The industry can’t do what it’s done in other industries, which is squeeze out the inefficiencies and create, really, a seamlessly integrated experience. Look at the financial sector, elsewhere. Nor can government do this because it doesn’t have control, and I think it has a lot of conflicts of interest with respect to how to make health care work versus the Medicare Trust Fund be solvent. And so you see kind of that being … now sitting at a point of maximum agony. I think that’s going to flip one way or the other. So we could have a very government-controlled system that’s consumer responsive or a government-controlled system that is quite provider-driven, and we could have a private-sector system that’s one or the other.”


December 4, 2006

IT Phone Home

Filed under: — mlazoff

Use of Mobile and Wireless Technology Jumps in Hospitals, according to an article posted two weeks ago in Digital Healthcare and Productivity.com (the new name for Healthcare IT World News). “Even though adoption of electronic health records (EHR) and other clinical IT remains fairly anemic, at least one aspect of health-IT has taken giant steps forward in the last few years: the use of mobile and wireless technology where choices are proliferating.” Mobile technology here are essentially PDA smart phones with built-in Wi-Fi or Bluetooth wireless functionality. Technology has improved over just the past few years; according to the article, the time it takes to download images has decreased from 30 seconds to 3 seconds. Although screen size and resolution on these devices still do not allow for quality graphics, the article quotes several physicians who state that consulting on emergency conditions does not generally require subtle findings in CT scans or EKGs. The article goes on to describe upgrades in the major wireless networks, and how local area networks (LANs) such as Wi-Fi hot spots are bridging technology gaps. Specific LANs operating in hospital complexs are also described.

“And there’s another side benefit of the mobile devices. ‘Our kids, in particular, just love us carrying around our iPaqs,’ says [Julie] Massey, MD, a pediatrician.”



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