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The Fickenscher Files, Vol. 14
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Quote Of The Week

"[It is] a distinction without a difference. When I was growing up in Arkansas,
we called it straining at a gnat and swallowing a camel."

Former President Bill Clinton, in his new book, Back to Work [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-o0ZjObj31cUZEk2Rq0_b8n-s-vPIPjA_eoAGlFVxbjl8LHA4D8AeMQTySOyrgrC5-GtM0jpjw2AgrJmLAwmYNkCdxTb-H75Da6fUg2U105n4HE0pm-14YxTme98DhdRo0bLotdxDOiOioagIDv444AB-ac33zBDTa5YdUmvGGMnAZtSxeItNHIWGsRfHg6s_DT67WG0dkUabJQAlxiHgKxhWNcj0ig4aMGcLWPKa-UQJtBuBmj-InKyrZOuQSPnVOTMiqLBw6iz75BTKv8TpUANr4yU72WIW_OfdS4516iNQ==],
in describing the practical difference between a tax credit and a spending increase.

"If we don't get this right, we could mess up the insurance market rather than improve
it. We really feel this is so new to most people, it's worth laying the right ground
rules."

Judy Waxman, Vice President for Health at the National Women's Law Center in discussing
the impact of implementing health information exchanges as required under the Affordable
Care Act passed in March 2010.

Consulo Indicium

Information for your Consideration...

Device Miniturization Continues - A pocket mobile echocardiography device that only
weighs 14 ounces and measures only 5"x3"x1" is now available on the commercial market.
Echocardiography is a procedure where sound waves are bounced into the heart to
measure how effective the heart is in pumping and in finding abnormalities such
as problems with values and the heart wall. The standard test is referred to as
the Traditional Transthoracic Echocardiography. Researchers recently reported in
the Annual of Internal Medicine (2011 Jul 5, 155:33) [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-qpO3QDS8ZxG5pyIT9rfs5qt6SqbPtX2paoWdGKoObfpb4ILBysIqMzyrADjLrVJbw2X5REnyMiKG5eHaqytlvZ-cngi6-Y3aZtW9Ofoml4mdth_2fmKu9lpDSBKD341js=]
that the accuracy of the mobile device compared to standard TTE was 91% for ejection
fraction, 74% for wall-motion abnormalities, 79% for aortic valve pathology and,
77% for mitral value pathology. Another interesting finding was that body mass
(i.e. weight of the patient) had a substantial effect on the accuracy of the test.
These devices are clearly moving into the cardiologist's exam room. But, more
importantly - as the accuracy improves - they will be moving out of the exam room
and into the community. The implications are profound, and the heart is only the
first target for these mobile devices. The use of mobile technology will dramatically
change who, where, and how healthcare is delivered in the future and, it's moving
a lot faster than everyone thinks...

A Pre-Thanksgiving Admonition - It's More than Brocolli - Well, it seems that our
health is tied to more than the green vegetables. The Dutch recently released a
study of over 20,000 individuals who were followed for 10 years. The study showed
that people who ate white fleshed fruits (e.g. apples, bananas) and vegetables (e.g.
cauliflower, cucumbers) had a 50% reduction in their risk of stroke. So, while
the green vegetables seem to help the heart, the white vegetables seem to help
the brain. The theory is that the white vegetables have lots of dietary fiber and
contain a fair amount of natural anti-inflammatory products so blood pressure is
lowered - leading to a lower risk of stroke. The message? Don't forget the white
fruits and vegetables. I guess that means we have to clean our plate when it comes
to the vegetables and fruits...

The Unreal Computer Scare - In a recent article in Slate.com, Farhad Manjoo [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-qb4v5LYLphZdWrvjN1xgjJOfIQf98pc0psTRUKS0BtjYPRXh6TeXJYANUEo5EprURC2KbuYd6o38fMrHSB3UNaeWnbjKLuPdx6MJV8GdkwPD__2JUmMMHxdMZFkRWLCFMuvscH1BbHys4Sl8oUKE-NshxAvY7ie0v4A1r_nN-v0YWDTMGttRqYOT7Bekl3BiGSHILmt0KoT_JxjLk0hMoitHNyFHKijy4=]
made a series of daring statements about the impact of computers on work. His predictions
include statements that computers will be replacing humans, "You are in peril",
"...there's a fair chance" that repetitive tasks will be replaced by computers.
In particular, he highlighted physicians, lawyers, pharmacists and even writers
as professions that were at risk! In talking about pharmacists, he noted that robots
can "look up patient records, count out pills, label vials, and bill insurance companies"
faster, cheaper and more effectively than we humans. So? That's the whole point!!
I think the point is lost with the scare approach. Computers, robots and all of
their cousins are simply "tools" that can be used by all of us to do a better job,
more effectively and more efficiently. With the looming shortage of healthcare professionals
not only here in the United States but also worldwide, I welcome the computers and
all of their derivative capabilities. I say, "Bring it on!" By adopting technology,
I believe we will address the three biggest concerns of most Americans when it comes
to healthcare. One, we will reduce the cost of delivery. Two, we will increase quality.
And, three, we will enhance service. It's that simple. Now, that should not scare
anyone...

Energy Demands Grow Worldwide - China and India will account for 25% of global energy
use in 2011. By 2035, these two nations will consume over one-third of the world's
energy. We should be focusing our nation's policies on efficiency, reduction in
consumption and alternative supplies. The traditional resources are drying up. Alternative
energy sources need to be our focus. My home state of North Dakota has enough wind
to supply about 25% of the nation's electrical needs but, we don't have a grid for
delivering the electricity. It seems to me that we should be working more diligently
to get ahead of the curve...

Mental Health and Children - I was provided some interesting information this past
week related to mental health services for children. First, approximately 5 percent
of all children are in need of mental health services. Second, half of all lifetime
cases of mental illness begin by age 14 and three quarters by age 24. But, only
about 20 percent of youth with mental illness actually receive treatment. What is
even more disconcerting is that typically there is an 8- to 10-year delay between
the onset of symptoms and intervention, which results in severe consequences in
behavioral, emotional, and mental development. Finally, there are only 8,700 child
and adolescent psychiatrists in the United States, a shrinking number of acute psychiatric
beds for children and adolescents, a desperate lack of residential treatment facilities,
and an insufficient number of outpatient treatment programs. Clearly, we've got
a problem. Mental health, in general, is the neglected child of the healthcare system.
We can do better...

Skyrocketing Medicaid Costs for the States - The states are facing a major dilemma.
State Medicaid spending is projected to grow by an average of 28.7% for the current
fiscal year (NOTE: FY12 started on July 1st and note the following table). The increase
in Medicaid spending is the biggest increase in the history of the federal-state
health insurance program for the poor and disabled, according to a Kaiser Family
Foundation report released last week [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-qkO0W7IntzXLBuFwn9GMm-GZ3EeEsOjLKLSAcgnRmBGUgpiY8aXaadgAa6_iDSTnnjJmw9wPl3xHgKK1WC_eOIyZNMdzMr24QJovcj397jw6dgHDqPsXg0MrI-jZ2282I=].
The primary reason is the loss of federal stimulus money, with the states having
to pick up the difference. The loss of federal money is compounded by the loss
of state revenue as a result of the most recession. Also, because of the recession,
Medicaid enrollment increased significantly. Over the last decade, state Medicaid
spending has generally increased about 5 - 10% on an annual basis. Now, the states
are scrambling to make up for the loss of billions of federal dollars. Some of the
state cost containment actions include: restrictions on payments to providers and
benefits, new copayments for beneficiaries, initiatives to contain costs of prescription
drugs, expanding the use of Medicaid managed care programs, moving long-term care
toward community-based care models; and, streamlining enrollment procedures

The Electronic Health Record Comes Of Age
Attorneys rush to keep pace with electronic health records...

I've previously discussed in a prior edition of the Fickenscher Files [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-qhUdT3GG0zGFCysqSaBZLF3938MG-eZfSNLQ3PJ99I1DaKMoSpXTkiXK84e14dpaIXlKRS6rqakrlXEp3bG3b31ATVVzPkmz4j-cSm8SQi630WgT8vOBAgTlsrSHjqXL31-RTHk27e3Y7mrygKK-ejYijC0mF5rNNh3ymf7ktitqLw_j_NCkjD_lDkpBGv82k=]
that Health IT (HIT) can deliver on its promise to improve patient-care quality.
But, I've also learned over the years that switching from paper to electronic medical
records isn't easy. It requires a transformation in the workflow and processes of
the physicians and support team who are involved in the care delivery process. As
we move rapidly into the new world where use of electronic health records (EHRs)
is becoming more or less mandatory, some tough questions are evolving. For example,
what constitutes the legal medical record in an electronic world? Is it only the
physician's office and hospital? What about the home health program? And, there's
the walk-in clinics at CVS, Walgreens, RiteAide and others who are providing some
of the primary care for individuals. With the advent of health information exchange
(HIE), the question of the legal record is becoming an increasingly important consideration.

Last August, scores of attorneys and informaticists gathered in Chicago to address
the question at the Legal EHR Summit [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-o_HBy6JEtZgw45jE4C8IpyS6DayCKVUbOGL3O4ckG439eviwyTTMLu_LYH8pKGuajeD_pv14mFRxdsxIn5zi9l_64KVBybEsglpdsrtQ1U6nT_m80VjzdfesUJ5CxC2rkEiLu5rlsXHW0c4hkfD0mPXW-GNMDXUuMltY_zxHU9Z4XZcTBLg6TUl1gBfCYT0G-HLySeEVuW3g==],
which was sponsored by the American Health Information Management Association (AHIMA).
As a result of the dialogue and discussion, some unexpected challenges were raised
at the summit that health care executives will be facing in the future.

Not too long ago, physicians filed everything in single, plain manila folder for
each patient. And, few people had access to the file. Even if they did, it frequently
was not legible and many cases - depending on the clinician - providing only cryptic
information on the patient. But, physicians also held knowledge of the patient from
their personal interaction with them over time. So, the medical record was a mixed
bag. Now, EHRs are designed to be seen (and revised) by many more clinicians who
must navigate through dozens of screens and alerts for each patient. Complexity
has increased exponentially. With the volume of data now captured into a single
record, you can imagine the challenge of recreating the experience of a clinician
who accesses the EHR in a straightforward manner for attorneys, juries, and judges
who are considering the information due to medico-legal considerations. A priori,
in designing these systems, the clinical informaticists have focused on the requirements
of physicians and other care providers, not attorneys. However, it's increasingly
obvious that supporting back-end legal medical record requirement is equally important.

One important issue is how the system accurately identifies patients. It's a serious
challenge, especially for large urban hospitals. For example, one county hospital
in Texas has 3.4 million patients on file. The patient list includes 231 women named
Maria Garcias with the same date of birth date, as reported by Indranil Ganguly,
the CIO of Centra State Healthcare System. I understand this issue intimately.
My son, Kevin Jr., was born on my birthday and, we worked at the same company. Keeping
our records straight was a major challenge. The day he started, the HR department
switched my salary to him. Imagine the consternation. It happened because the record
was incomplete and someone along the line made the assumption that we were one and
the same person. Kevin, Jr. was very accommodating; however, and we got the problem
turned around quickly. But, we had access to the system. Any one of the 231 Maria
Garcias' most likely did not have access nor, did they even know there were others
with exactly the same name and birth date. Anyone searching the record most likely
could have found the right file for the right Maria by using her social security
number. But - just like me and my son - many records are incomplete, so that's
no guarantee.

One answer to the problem is to assign a unique ID number to each patient, which
was originally included in the1996 Health Insurance Portability and Accountability
Act [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-oKeuI0EQl2T0HOaiOG3VDGMaicy9IXv-W2J85zeIFI2Wnkt6Oy-veTnkE43gqG4mQCcE9BNcs28DhBV-qCOx8nJz5Kc97igj1H_v7uLAFu_uVSztZv1eSM]
(HIPPA) initiative. However, Congress later revoked that plan after privacy watchdogs
complained. Without unique patient IDs, hospitals and physician practices resort
to using complex algorithms for matching data so that the right information ends
up in the right place. Despite the sophistication of these technologies; however,
they fail up to 12% of the time. So, solving this problem is a crucial consideration
among those of us in the health information field.

While on the surface, the use of clinical information technology may appear simple,
behind the scenes these systems frequently integrate a web of different systems,
formats and data from various locations. The end result is that it is extremely
difficult if not impossible to recreate what the user saw at the point of care
as pointed out at the summit by Michael Slovis of Cunningham, Meyer & Vedrine [September
[http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-oDjRU0tWUnJWGyjq3eUhScj7MGbyYIKZ_Z1cQBvyTUjL23QtIQHZqJH52BVJZpeJPgr1vTBoYxDHMr4VmyDZtHyfgcT_vGABcsGe1cKEz3IkIYgBYsi11v919uGDQ-18OMix3j2veAcf3Is5A-TxtEEDAQXUNUbJ8=]
2010 Healthcare IT News [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-oDjRU0tWUnJWGyjq3eUhScj7MGbyYIKZ_Z1cQBvyTUjL23QtIQHZqJH52BVJZpeJPgr1vTBoYxDHMr4VmyDZtHyfgcT_vGABcsGe1cKEz3IkIYgBYsi11v919uGDQ-18OMix3j2veAcf3Is5A-TxtEEDAQXUNUbJ8=]].

Federal and state standards related to the exchange of health information are still
in an evolutionary state. In the coming years, expect a flurry of discussion on
this topic. It will be driven from a number of vantage points: the clinicians,
the healthcare systems, the IT integraters, the lawyers, the consumer advocates
and others. In many respects, we are entering a tidal wave of changes similar to
what has been experience in other industries such as music, movies and books. Disruptive
technologies like iTunes, NetFlix, and Amazon's Kindle e-reader have changed the
name of the game. In a similar fashion, the electronic health record (EHR) is a
disruptive technology that changes the rules of the game for healthcare. And, like
our counterparts in other industries, we are likely to struggle in our efforts to
keep pace with the seismic shifts in our business and care delivery models. We must
be prepared for some unexpected and unintended consequences as we proceed with the
deployment of EHRs in the health care industry. That said, it's clear to me - and,
from the literature - that the benefits of clinical information technology far outweigh
the drawbacks. After all, who would give up their iPod for an eight-track player?

Improving Health Under the Primary Care Medical Home Model
The outcomes data shows that the new model actually improves care...

At a recent meeting of the Patient-Centered Primary Care Collaborative (PCPCC) -
which has been a prime supporter of the patient-centered medical home model - researchers
noted outcomes data that demonstrates improved quality, greater patient access and
lower costs in PCMH pilot projects. One of the projects highlighted at the conference
was from my home state of North Dakota. The program is sponsored by Blue Cross and
Blue Shield of North Dakota and is known as the MediQHome program. It started in
2009 and now provides care to 280,000 state residents, including 72% of all BCBCND
patients. Even more impressive is the fact that 72% of all primary care physicians
in North Dakota participate in the MediQHome initiative. Like most patient-center
medical home programs, MediQHome focuses on managing common chronic diseases. With
the aging of the North Dakota over the last 10 years, there has been a dramatic
increase in such problems.

During the PCPCC meeting, BCBSND representatives presented outcomes data from MediQHome
such as data indicating that blood pressure control among the 30,298 patients with
type 2 diabetes in the system had grown from 74% to 79% during a three-year period;
and, LDL cholesterol levels of less than 100 had grown from 58% to 64% during that
same period. Other examples include the fact that use of the ER is 30% lower among
MediQHome patients with chronic illnesses than those patients with chronic illnesses
who are enrolled in traditional insurance programs. Overall, ER use in the state
increased by 8.4% among the general population but decreased for MediQHome patients
by 7.3%. That represents a substantial cost savings. Furthermore, the inpatient
hospital admission rate among patients the medical home patients was 18% lower than
that in the general population. Again, an impressive outcome... Other examples which
were reported at the meeting include:


* Group Health Cooperative of Puget Sound in Seattle experienced a 29% reduction
in ER visits and an 11% reduction in ambulatory care- sensitive admissions among
its medical home patients.
* Geisinger Health System in Pennsylvania realized an 18% percent reduction in all-cause
hospital admissions, a 22% improvement in coronary artery disease care, and a 34.5%
improvement in diabetes care.
* Blue Cross Blue Shield of Michigan (BCBSM) in their medical home initiative registered
a 9.9% reduction in adult ER visits compared with a 6.6% reduction among adult patients
in non-PCMH practices; a 13.2% reduction in pediatric ER visits compared with an
8.8% reduction among pediatric patients in non-PCMH practices; and, a 22% reduction
in adult ambulatory care-sensitive inpatient discharges among BCBSM medical home
patients compared with an 11.1% reduction among adult patients in non-PCMH practices,

The Patient-Centered Primary Care Collaborative also recently released two new publications:
Core Value, Community Connections: Care Coordination in the Medical Home [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-qQcXaep8_GeRKAUFLKwwNpasIhjpzQOTJ-x4DmMnIBtUdscUDg_YGe2l_RwOOfnlzU2osP0VxZuYXnfJfLtkdXmnHfZUVjIRqTWfNUxB2UUyBbbtSpYE0bWPW6etIdgelqY_1CPW6faQ==]
and Putting Theory into Practice: A Practical Guide to PCMH Transformation Resources
[http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-p0Oyjy4bhHn691622VCXcZzgSvh0V9IsNNUJ_lb84juXwr2mALe-yGzrDYBXeG938ZC7gT4uQ06VtLrnSbtobrXpMJCB70n0SSKNestUReFWYzC_42S-umQNCJWJmsUOA3H5NFlwPvFA==].
For those who are interested in moving forward on these types of projects, these
two publications are essential reading. So, it's becoming increasingly clear -
the patient-center medical home model works. It increases quality and reduces cost.
I suspect that if we did a survey of the patients, they are also more satisfied.

The Weekly Whisk

Musings from a foodie...

Every once in a while, I find a hidden gem of a restaurant that is local or that
few people know about. Such is the discovery of TJ Buckleys [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-o-mSuxXsfoUEHsRwyGQkZtT1pHJsi3w9vSVulB-6A7nvA_zxoCOJy5qK9V8Gu28RCWdUCQabEs8kzmo8mBtc6Ki99aoDXrn7Ry8fDI9KK3IA==]
in Brattleboro, Vermont. They were voted the best restaurant in Vermont for 2010.
And, what a find it is [****]. Michael Fuller has been the Chef and Owner for the
last 28 years. He is a self-taught chef and a master at presentation. If you get
up to that neck of the woods in Vermont, this is definitely a place to check out
but, you'll need to make reservations in advance. The place only seats 20 and most
nights they are sold out.

I started the evening with a duck pate that was accompanied by four different apples
sliced in a very thin fashion along with both sweet and sour dill pickle slices.
All of this was drizzled with a mustard, cayenne and vinegar sauce that was incredibly
good. Not only that - but, the presentation also had very tiny flowers in each corner.
It was a beautiful piece of foodie artwork. Following the pate, a cheese torte using
ricotta and parmesan cheese was presented with Swiss chard and raisins all served
on a bed of wonderful phyllo. The mixed salad that followed had a wonderful vinagrette
dressing with tiny blue cheese sprinkles to accompany.

And, to follow - the entres were supurb. There was a wonderful rabbit drenched in
a complex cabernet sauce along with wild salmon. It could not have been better.
I was very surprised to find this wonderful little eatery in such a small town but
that is the pattern in much of New England. If you get close to Brattleboro, you
should definitely stop in but don't wait too long as the wait list is not inconsequential.
Check it out @ http://www.tjbuckleys.com/ [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-o-mSuxXsfoUEHsRwyGQkZtT1pHJsi3w9vSVulB-6A7nvA_zxoCOJy5qK9V8Gu28RCWdUCQabEs8kzmo8mBtc6Ki99aoDXrn7Ry8fDI9KK3IA==].
TJ's is only open Wednesday through Saturday so that may impinge on your culinary
pleasures but go for it. TJ Buckley's - 132 Elliot Street - Brattleboro, VT 05301
- (802) 257-4922.

The Good, The Bad, And The Ugly

The ongoing saga...

The Good - The economic showdown in Europe between the powerbrokers in Germany and
France with the politicians in Greece who decided it was better to accept austerity
requirements than to continue arguing while their economy went further into the
ditch.

The Bad - Over half of ICU rooms cultured positive for a superbug Acinetobacter
baumannii according to a study published in the American Journal of Infection Control.
Clearly, this is a cause for concern because the surfaces are routinely touched
by health care workers and spared of the superbug is real potential problem.

The Ugly - Discussions switch from Greek to Italian over the next several weeks
as the world economy turns its attention to the next economic problem child in the
European Union.

The Really Great - Aaron Rodgers is the new Brett Farve who for a long time was
the new Bart Starr in the line of succession of great Green Bay Packer quarterbacks.
Aaron did an outstanding job against the San Diego Chargers!!
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Founding Sponsor
Dearborn Advisors, LLC [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108570570286&s=6409&e=001vi_1CRTsw-qKWWtxiIDkcUwmu_IzIJsfiXyCyF9eOxkXDx47Ce26j0zPALP4u4iefXXZQOwKk4Bguc2Ty9xxPwEvYslcnSv1W6vBHK5iXgi2s7jgNnWXagaoF_nP3BTH]
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