Screening Guidelines And Ageism

Most of the controversy surrounding mammography involves when to start screening - 35? 40? 50? However, the US Preventative Services Task Force has also suggested that the evidence for continued screening after age 75 is lacking. Now there may be some evidence for older women.

Malmgren et al from the Swedish Cancer Institute in Seattle reported on findings to suggest the benefit of continued breast cancer screening in older women.

The researchers recently looked at the impact of mammography detection on older women by studying data from an institutional registry that includes more than 14,000 breast cancer cases with 1,600 patients aged older than 75 years.

The majority of mammography-detected cases were early stage, while physician- and patient-detected cancers were more likely to be advanced stage disease. Patients with mammography-detected invasive breast cancer were more often treated with lumpectomy and radiation and had fewer mastectomies and less chemotherapy than patient- or physician-detected cases.

Mammography detection was associated with a 97% five-year disease-specific invasive cancer survival rate, compared with 87% for patient- or physician-detected invasive cancers.

“Mammography enables detection when breast cancer is at an early stage and is easier to treat with more tolerable options,” said Dr. Malmgren. “In this study, older women with mammography-detected invasive cancer had a 10% reduction in breast cancer disease-specific mortality after 5 years.”

This all has little to do with ultrasound but everything to do with the doctor patient relationship. Ultimately, the decision to screen or not to screen should properly rest with the patient and her doctor, based on medical evidence, not cost. Older folks are people too.

If you've any questions or need to schedule an ultrasound, please call (718) 925-6277.

New Fertility Hope For Chemo Patients

From this weekend's New York Times:

A commonly used drug can help young women with breast cancer retain the ability to have babies, apparently protecting their ovariesfrom the damage caused by chemotherapy, researchers reported here on Friday.

The treatment could provide a new option for dealing with one of the painful dilemmas faced by young cancer patients — that doing the utmost to save their lives might impair or even ruin their fertility. Researchers said the drug, goserelin, which temporarily shuts down the ovaries, appears to protect women from the more permanent premature menopause that can be induced by chemotherapy. In a clinical trial, women who were given goserelin injections along with chemotherapy had less ovarian failure and gave birth to more babies than women receiving only the chemotherapy.

“Premenopausal women beginning chemotherapy for early breast cancer should consider this new option to prevent premature ovarian death,” the study’s lead author, Dr. Halle Moore of the Cleveland Clinic, said at a news conference here at the annual meeting of the American Society of Clinical Oncology.

This is wonderful news indeed for many young women awaiting chemotherapy. There is one catch, however. On the GoodRx website, Zoladex (Goserelin) is listed as:

This drug is considered a specialty medication, which means:

It is very expensive. A typical fill can cost $1,326 or more for 1 kit of Zoladex 10.8mg.

Patients in need of this drug will usually find most of the cost paid by an insurance company, government or non profit organization. If you are uninsured or need help with your co-pay, the manufacturer may also offer assistance.

Most retail pharmacies will not stock this medication. The manufacturer may offer more information on how to fill this prescription.

Physicians and patients considering this therapy as always should do some homework first.

For more information, or to schedule an ultrasound, please call: (718) 925-6277.

Cervical Cancer Rates Rising in Seniors

Recent changes in pap smear frequency suggest that pap smears may no longer be necessary for women 65 years of age or older. There are a few big IF's:

Those with three consecutive negative Pap tests in the last 10 years, or two consecutive negative Pap tests combined with negative HPV tests in the last 10 years, with the most recent test performed within the past 5 years.

Now comes this news.

Previous studies determined that the rate of cervical cancer was approximately 12 cases per 100,000 women in the U.S. The incidence of the disease peaks in women between 40 to 44 years, then tapers off. However, such estimates did not take into account women who had hysterectomies, and are therefore no longer at risk for developing cervical cancer. Once these women were factored out, the incidence of this type of cancer increased to 18.6 cases per 100,000 women. The rate steadily increased as women age, particularly in women between 65 and 69 years of age.

African-American women had a higher incidence of cervical cancer at nearly all ages compared to caucasian women, with the discrepancy becoming more pronounced at older ages.

The study’s lead author Anne F. Rositch, Ph.D., M.S.P.H., an assistant professor of epidemiology and public health at the University of Maryland School of Medicine and a researcher at the University of Maryland Marlene and Stewart Greenebaum Cancer Center, believes these findings are important when reevaluating the screening guidelines for cervical cancer in older women in the U.S. Appropriate interventions need to be initiated to lower the burden of cervical cancer in these women.

Will the abandonment of the annual pap snatch defeat from the jaws of victory in the fight against the cancer that killed Evita Peron? While we do not want to spend precious healthcare dollars on needless testing, we do not want to put women's lives at risk in the process. I would urge any woman to have these conversations with her doctor before choosing either to continue or to forgo pap smears. Choose wisely indeed.

For more information or to schedule an appointment for an ultrasound exam, call: (718)-925-6277.

Hepatitis C: To Screen Or Not To Screen, That Is The Question

Recently, NY State passed a law requiring screening for Hepatitis C be offered to all patients born between 1945 - 1965. Hepatitis C is a potentially fatal disease which can attack the liver silently over time. It is thought that as many as 1 in 30 "Baby Boomers" could be infected with the virus. For these reasons, screening this group makes sense. But of course, as always, there is a catch. It seems the cost of treatment for those infected is prohibitive for all but those on research protocols, better than platinum insurance plans, or those with incomes in the Warren Buffett range. Sovaldi, a new drug for Hep C treatment, costs about $84,0000 for a 12 week treatment.

What can be done about the cost? Right now, not much save to check with your insurer about treatment coverage and copay, etc. Still think screening asymptomatic folks is a good idea? For each individual, the answer may be different. Before asking a question, it's always best to know what you'll do with the answer.

Disruptive

There are many disruptions in the flow of care these days, especially in the Emergency Department. However, Disruptive has taken on a whole meaning lately, what with the proliferation of mobile and even wearable tech. Today, I cam across this post by Dr. Teresa Wu..

...As you are supervising two of your residents putting in bilateral chest tubes, your eager medical student runs up to the trauma bay with a pair of Google Glass. You are researching ways to incorporate wearable technology like Google Glass into your clinical practice and medical education so you and your medical student have a few pairs of Glass with you at work. You put on Glass and ask your medical student, “What can I help you with?” He informs you that your senior resident wants you to take a look at an ocular ultrasound of a patient he staffed with you a little while ago. He knows you are going to be tied up in the trauma bays for quite some time and wants to know if he can discharge the patient with ophthalmology follow up.

...You turn on Google Glass and link to your senior resident who is also wearing Google Glass while performing the bedside ocular ultrasound (Image 1). Through Glass you can see the ultrasound screen as he views it. What does the B-mode ocular ultrasound demonstrate? What’s the patient’s diagnosis?

Bedside Ultrasound meets Google Glass. Read the whole thing.

Just Wow!

EMR: Promises Unfulfilled

Welcome to my nightmare.

My practice is limited to consultative ultrasound in Obstetrics and Gynecology. It's been that way since the mid 1980's. My routine used to be simple. A medical assistant or sonographer would escort a patient into the exam room and take a history, inserting pertinent information on a report form. Patient identifiers would then be entered into the name and data fields on the ultrasound screen. After seeing that the patient was properly set up and doing some preliminary scanning, I would be called in. After asking the patient a few questions and a little small talk, I would then perform the ultrasound exam. I would give the patient a synopsis of my findings sans medicalese and then leave to write a preliminary report. The chart would then go to for transcription and from there to billing. Life was good.

Then I joined a large health system which had incorporated all the 21st century technology, including both an EMR and Ultrasound Reporting software as well, neither of which talk to each other. My routine is considerably different.

Now I am either handed a stack of demographic info or obtain my own demographic info off a computer screen. I then enter this data into another computer screen. This is invariably incomplete as it's usually unclear who referred the patient and to whom the report will be sent. A medical assistant fetches the patient and escorts her into the exam room, but usually I am the one to enter the info into the data field in the ultrasound machine. I am most often the one now who takes patient's history. I also figure what needs to be done and in what order. I then leave the room so the patient can change. After an appropriate interlude, I return and perform the ultrasound examination. I again give the patient a synopsis of my findings and then leave to write my report.

I return to the computer and then finish entering the demographics and some historical data. Because the images are usually not incorporated with a patient's demographics (remember, I couldn't enter that until I spoke with the patient,) I have to "attach the images" to a patient. Then I am ready to write my report. I pull up an image and input data from it into the appropriate field in the report page. I find some fields arranged in a nonintuitive fashion. I entered descriptive information by keyboard now rather than pen as I am now the transcriptionist.

Periodically, I have to launch an additional program to find the appropriate diagnosis codes so the examination I performed can be justified. The present diagnosis code system of about 14,000 codes is set to switch to a whole new system featuring 70,000 codes, which will not make my life any easier. After completing the report and seeing that the exams are entered, the indications are entered and they all are coded, I electronically sign the report and then send it to a network fax driver. Unfortunately, because many of these reports find themselves mysteriously transferred to Altair 4, I also print the report and then walk over to a fax machine to do that myself. In some cases, when the patient's physician is in the same group of offices, I will leave the report with the office staff to be scanned into the EMR. (Remember, I told you the EMR and the reporting software don't talk to each other.

Looking at the two practice systems, I ask myself which system enhances productivity? I used to be a doctor. Now I not only see patients, but I'm a transcriptionist, a biller and a coder as well. And this in a health system with an army of billers and coders. I am not the only practioner with these issues. I can tell you that the increased time subsequent patients wait for their exam because I am dealing with tech issues is not boosting my patient satisfaction scores. But that's a topic for another day.

Health Insurance Does Not Assure Access To Care

The Mother of All Patient Access Battles is shaping up.

Americans who are buying insurance plans over online exchanges, under what is known as Obamacare, will have limited access to some of the nation’s leading hospitals, including two world-renowned cancer centres.

Amid a drive by insurers to limit costs, the majority of insurance plans being sold on the new healthcare exchanges in New York, Texas, and California, for example, will not offer patients’ access to Memorial Sloan Kettering in Manhattan or MD Anderson Cancer Center in Houston, two top cancer centres, or Cedars-Sinai in Los Angeles, one of the top research and teaching hospitals in the country.

After January 1, expect to see these signs in many doctors' offices.

It's For The Children

In today's NY Post, I come across this gem.

... Kelly said he was no fan of the Affordable Care Act, but when he received notice a few weeks ago that his current insurance plan was being canceled, he tried the New York State of Health Web site.

Kelly, 41, and his wife, Jennifer, 42, are self-employed and have always had to buy their own insurance. Kelly runs a title insurance business in Westhampton, and his wife is a pediatrician in private practice in Miller Place. “I initially went on with a lot of optimism,” he said.

Kelly said none of the plans offered out-of-network coverage, which was something he wanted. But even worse, they only covered his three older children, who are 3, 5 and 6.

When Kelly called a representative, he was told his daughter had to be 2 before she could be covered under a family plan. He would have to buy a separate plan for her, at monthly premiums that ranged between $117.21 and $369.31. The cost would be on top of a family plan with premiums ranging from $810.84 to $2,554.71 a month.

Let's back up a minute - pre-Obamacare - a family plan covered family members. Now, at least with one insurer in NY State, a family plan doesn't actually cover the family? And this is OK with NY State and the Feds? Who dreams up this mess, Old Man Potter from It's A Wonderful Life?

Head -> Desk.

Lemon of a Law

If PPACA, aka The Unaffordable Insurance Act, were a car, folks could recoup under the lemon law. We now know that if you like your plan, despite the president's "fix," you probably can't keep it. Some states like NY have already said it's too late to roll back that clock. Other states might be willing to go along but it depends on state regulators.

We also learn that if you like your doctor, you may not be able to keep your doctor. You may not be able to use your local hospital either, for that matter. Insurers have been both cutting their networks and decreasing their share of the payments to the doctors and hospitals for their services. Some prestigious NYC hospitals, like Langone Medical Center, have declined to participate in many of the new plans. Many doctors are also declining to participate or find (att some difficulty, I might add) that they've simply been dropped from the networks.

Without going into the Epic FAIL that is Healthcare.gov, many who are able to get to shop for insurance are experiencing firsthand the meaning of sticker shock. I guess that promise that folks would save about $2500 on their insurance costs was an "incorrect promise" also.

I ask you, when did we elect Joe Isuzu?

Honey, They Shrank The Network

Repeatedly, President Obama reassured us that "if you like your doctor, you can keep your doctor. Now, we learn the President may have pulled a fast one.

... Elderly New Yorkers are in a panic after getting notices that insurance companies are booting their doctors from the Medicare Advantage program as a result of the shifting medical landscape.

That leaves patients with unenviable choices: keep the same insurance plan and find another doctor, pay out of pocket or look for another plan where their physician is a member.

New York State Medical Society President Sam Unterricht is demanding a congressional probe after learning that one health carrier alone, UnitedHealthcare, is terminating contracts with up to 2,100 doctors serving 8,000 Medicare Advantage patients in the New York metro region.

While other carriers are similarly cutting doctors from their provider lists, United seems clearly head and shoulders above the rest.

Curiously, United is now involved with another aspect of Obamacare - the Obamacare website fix.

The government on Friday named a UnitedHealthGroup Inc. subsidiary as “general contractor” to oversee the troubled federal website designed to sign up Americans for health insurance under national health care reform.

When QSSI was awarded the contract to build the Obamacare Data Hub, questions of conflict of interest arose. In fact, when the QSSI purchase flew under the SEC radar, Sen. Orin Hatch raised the issue.

... He asked Health and Human Services (HHS) Secretary Kathleen Sebelius in an Oct. 19 letter for a full account of contractors hired to set up the national exchange and a list of administration officials who signed off on those awards.

“I am seeking more information about the contracts associated with the entities selected to build the federally facilitated exchange (FFE) and the federal data services hub that will support the FFE,” he wrote.

Hatch wants to know whether HHS reviewed UnitedHealth Group’s purchase of QSSI to determine whether it creates conflicts. 

Make no mistake, the insurers are using the highly popular Medicare Advantage Plans as a test case. If they can successfully eliminate doctors and products which they feel are too costly for them, their efforts will soon expand to all their insurance plans and networks. People have to be on high alert and call their friends, employers and both local and federal representatives.

They told me that if I voted for Mitt Romney, corporate entities would soon control all aspects of healthcare in the US ... and they were right.

Smart Health Insurance Shopping

So you've seen those ads on TV and want to buy individual health insurance on the Exchange/Marketplace. You need to do some homework before you shop. The first thing you need to do is that if you have a doctor or doctors, you should make a list. It's important to know whether your physician will be participating in any of the plans you intend to buy. Remember the part in the President's speech about how you could keep your doctor? Well, that isn't necessarily so. 

If your doctor is not a plan participant, then you will have to consider the plan's Out of Network benefit. Some plans have better coverage than others. Also, many of the newer networks will have fewer, not more, physicians so Out of Network could end up being a major expense depending on your coverage.

You need to know is that the premium will not be the only cost associated with health insurance. The lower the premium usually means the higher the copayment and deductibles. This may not mean that much if you're young and without chronic illness, but if you find yourself seeing multiple physicians on a regular basis, these costs can add up quickly. The true cost of health insurance is much like the true cost of owning a car. The monthly payments are only a part of the story. 

Fortunately, you don't have to rush out and buy health insurance today. You have until mid-December to buy a policy whose coverage won't start until January 1. Ask questions. If you don't like what you're hearing, ask more questions. Make lists. Do your homework. To paraphrase the old Sy Syms commercial, an educated consumer is the best health insurance customer.

Think Your Doctor Is In A Funk? Your Doctor Would Agree With You

While most doctors are satisfied with their job, most agree the stress levels have increased in recent years, with one out of five admitting to feeling just plain burnt out. In an AMA commissioned study, doctors offered that the EMR was the number one negative factor impacting doctors' morale.

• "What we've created is a monster, when really what we were shooting for was good patient care," said a physician about the government's program to promote "meaningful use" of EHRs with bonuses and penalties. The extra time spent "working the chart" to satisfy meaningful use requirements, the physician said, takes away from face time with the patient.
• "I am not a clerk," added a cardiologist who complained how the technology increased data entry responsibilities. Sixty-one percent of physicians surveyed are like-minded, saying that EHRs require them to perform tasks others could handle.
• "The EHR is not just a one-time investment," said a physician with practice management duties. "It's a hugely expensive, ongoing, every-freaking-day investment."

Other complaints including information's being lost in a maze of data, confusing dropdown menus, and lack of a standard for interoperability. Doctors' offices still rely on faxing hard copy and then having to scan information back into the record.

The electronic record isn't the only stressor. Having to jump over multiple and ever-increasing regulatory hurdles compounds the difficulties doctors face. Struggling to meet government's "Meaningful Use" requirements may be the most prominent hurdle. While striving to provide better patient care by adhering to regulation, office visits take longer. Struggling to keep to the schedule shortens the time actually spent with the patient. Not only does this result in a less than satisfactory doctor-patient relationship but increases the likelihood that an error may occur, potentially, a serious error.

Additionally, some large groups base pay incentives on "productivity." This also impacts adversely on the time spent with the patient and the quality of that time. Finally, in an era of declining payment from third party payors, doctors feel it's not about profitability anymore - it's about viability.

So next time you think your doctor is stressed and rushing, he is. Why not take his hand and offer some encouragement? He'll thank you for it.

You can read the study here.

Life After Cancer

According to the American Association for Cancer Research, there are over 13 million cancer survivors living in the US today. That number is supposed to grow to 18 million by 2022. The CDC found that about half are women  and one third are younger than 65 years old. For younger survivors, the question of fertility is an important issue.

Today's NY Timess hightlights this concern.

... At one time, oncologists rarely worried about the reproductive side effects of treatment because so few pediatric patients survived. But as more children with cancer live into adulthood — death rates have plunged 66 percent since the 1970s — the landscape of fertility has changed. Doctors are offering patients preservation options at the time of diagnosis, and researchers are finding that for many survivors, the odds of overcoming clinical infertility are surprisingly good.

Last month, a large study in The Lancet Oncology found that about two thirds of female survivors who sought out fertility treatments as adults ultimately became pregnant — a rate of success that mirrored the rate among other infertile women. 

Women with newly diagnosed cancers need to ask about fertility-sparing options, now more available than ever. Doctors, in turn, need to broach the subject with their patients. Cancer does not have to mean the "End of the Line." There is life after cancer.

Oh yes, for one more week, September is Gynecologic Cancer Month.

It's All About The Data

Today, we learn Google is launching a healthcare company.

... Larry Page, chief executive, unveiled the venture, called Calico, with a characteristically ambitious and vague claim that “with some longer term, moonshot thinking around healthcare and biotechnology, I believe we can improve millions of lives”.

While outlining a highly ambitious overall goal for the new company, however, Google did not disclose any information about how much it would invest in the venture, which areas of healthcare science the spin-off company would specialise in, or what the initiative was likely to lead to in terms of new products.

Big Data is the big mantra. But we need to ask the critical question before things get out of hand: Who Owns The Data?

Stay tuned.

The Color of Debt

This morning, I had the pleasure of receiving an article  co-authored by MSSNY's former Student Councilor Robert Dugger MD, The Color of Debt. 

The conclusion -

Black medical students had significantly higher anticipated debt than Asian students. This finding has implications for understanding differential enrollment among minority groups in US medical schools.

Interestingly, whites did not fare as well as Asians either.

The study does have so e weaknesses, with more than a hint of selection bias. Nevertheless, the matter warrants serious reflection by policymakers and further investigation.

Kudos again to Dr. Dugger for this publication.

The Dark Side of Wellness at Penn State

Rising employee healthcare costs are the bane of employers across the country. HR departments deal with the issue of providing benefits while keeping expenses manageable. Wellness programs are one possible solution to this quandry - healthy employees need fewer services. But wellness itself may have costs as well. Recently, Pennsylvania State University launched its own wellness program, Taking Care of Your Health. However, in order to encourage participation, PSU chose a coercive stick rather than a carrot approach.

The plan requires nonunion employees, like professors and clerical staff members, to visit their doctors for a checkup, undergo several biometric tests and submit to an extensive online health risk questionnaire that asks, among other questions, whether they have recently had problems with a co-worker, a supervisor or a divorce. If they don’t fill out the form, $100 a month will be deducted from their pay for noncompliance. Employees who do participate will receive detailed feedback on how to address their health issues.

At a university where some employees earn less than $50,000 annually, the faculty members contended that an $1,200 annual surcharge for nonparticipation — or $2,400 if the employee has a spouse or domestic partner on the school’s plan when that person has the option of coverage from his or her own employer — amounted to a strong-arm tactic. What’s more, they argued, the online questionnaire required them to give intimate information about their medical history, finances, marital status and job-related stress to an outside company, WebMD Health Services, a health management firm that operates separately from the popular consumer site, WebMD.com.

This has sparked calls for a faculty insurrection. 

Over at The Healthcare Blog, Vik Khanna and Al Lewis suggest an alternative strategy for the outraged faculty.

... However, there is an alternative approach, and one that will break the bank in HR: get every preventive test possible and then get all the follow-up care you can for every conceivable dubious or positive result, many of which will be false positives.  Faculty should also use their paid time off to rest up from the physical and emotional stress of getting all this unnecessary medical care and perhaps even think about filing workers comp claims since these stressors are all directly job related.

PSU administrators thought they could slip this coercive program in during the summer downtime and that the white collar faculty, without benefit of union strong arms, would simply rollover and comply. They chose ... poorly.

Healthgrades Epic Fail

In selecting a new doctor, many check like to check them out online at rating sites such as Healthgrades.com. The more satisfied the patients, the better the doctor, right? Well, it ain't necessarily so. Check out the case of a Texas neurosurgeon.

... The article chronicles how a neurosurgeon in Texas permanently injured and likely even killed multiple patients during surgery and how the Texas Medical Board failed to timely respond to complaints that were raised. As a result, the neurosurgeon, Christopher Duntsch, continued operating on patients and patients continued having bad outcomes from his surgeries. 

This does not sound like a doctor I'd want to see or refer folks to, does it? Well, according to Healthgrades (until they scrubbed his profile,) this was a highly rated doctor.

... the same doctor who was reported to have caused the deaths of several patients and who reportedly permanently injured multiple other patients was rated as a 4.3 out of 5 in patient satisfaction. Dr. Duntsch rated above the national average in every one of Healthgrades’ patient satisfaction survey details except the total wait time in exam rooms – where he rated the same as the national average.

Now Healthgrades.com has decided to remove all of the satisfaction information from Dr. Duntsch’s profile, so all you’ll see is a bunch of blanks on his ratings page. But I got a screen grab of the ratings before Healthgrades erased them.

While patient satisfaction is important, high ratings are not equivalent to high quality care. As the author of the Whitecoat piece demonstrates, this doctors' patients thought highly of him until they woke up dead. The author goes further:

In fact, Healthgrades.com has many complaints about the accuracy and validity of its ratings. It is rated at the lowest score by 88% of all people giving it a rating onConsumerAffairs.com. I had one reader write me about how Healthgrades.com published that he was still seeing patients when he has been retired for 10 years, how Healthgrades published his home phone number, and how patients call his home phone number at all hours of the day and night, then yell at him because he is retired.

When physicians complain about such sites, what is the response? Press Ganey CEO Patrick Ryan suggests physicians "Suck It Up." Oh and did I mention that Healthgrades CEO Roger Holstein is a member of the Board of Press Ganey?

Quis custodiet ipsos custodes?

I Robot

It seems as if you cannot open a magazine, listen to the radio or watch a tv program without catching an ad for robotic surgery. The surgical robot is indeed a remarkable instrument with the potential to take minimally invasive surgery to a whole other level. However, the proliferation of surgical robots also has a downside. Witness today's NY Times:

... The new study follows a series of reports critical of robotically assisted surgery. Documents surfacing in the course of legal action against Intuitive have outlined the aggressive tactics used to market the equipment and raised questions about the quality of training provided to surgeons, as well as the pressure on doctors and hospitals to use it — even in cases where it is not the physician’s first choice and she has little hands-on experience.

Nevertheless, robotic surgery has grown dramatically, increasing more than 400 percent in the United States between 2007 and 2011. About 1,400 da Vinci systems, which cost $1.5 million to $2.5 million, have been purchased by hospitals, according to Intuitive’s investor reports.

The expansion has occurred without proper evaluation and monitoring of the benefits, said Dr. Martin A. Makary, an associate professor of surgery at Johns Hopkins and the senior author of the paper.

“This whole issue is symbolic of a larger problem in American health care, which is the lack of proper evaluation of what we do,” Dr. Makary said. “We adopt expensive new technologies, but we don’t even know what we’re getting for our money — if it’s of good value or harmful.”

As of yet, it's been difficult to demonstrate that the expensive robots result in outcomes that are worth the investment. ACOG released a statement on robotic surgery concluding:

... Aggressive direct-to-consumer marketing of the latest medical technologies may mislead the public into believing that they are the best choice. Our patients deserve and need factual information about all of their treatment options, including costs, so that they can make truly informed health care decisions. Patients should be advised that robotic hysterectomy is best used for unusual and complex clinical conditions in which improved outcomes over standard minimally invasive approaches have been demonstrated.

While it's a poor carpenter who criticizes his tools, periodically we need to know that a particular tool is, as R Crumb's Mr. Natural put it, "the right tool for the right job."

Also, if you are considering robotic surgery, be sure to ask the surgeon some very specific questions about experience, volume, and outcomes. 

Of course that's just my opinion. I could be wrong.

EHR's - The Forecast Is Cloudy

Though discussion of EHR benefits is still an open item, that costs can be considerable is universally accepted. For this reason, many physicians and hospitals are going to The Cloud.

Eighty-seven percent of all physician practices agree their billing and collections systems need upgrading, according to a new survey. The majority favor moving to a fully integrated practice management, EHR and medical software product, accessible through the cloud on any browser or device.

The first of eight revenue cycle management studies to be released by Black Book, the "Top Physician Practice Management & Revenue Cycle Management: Ambulatory EHR Vendors," is an analysis of the convergence of the replacement EHR market with the needs of physician practices to upgrade patient billing processes.

According to Black Book Rankings, the RCM software and services industry recently surpassed the $12 billion in the ambulatory physician practice segment 

However, as Andi Mann, VP of Stategic Solutions at CA, puts it, with new technologies come new risks.

The proliferation of cloud connected devices and users accessing data from outside the firewall demands a shift in the way we secure data. Security is no longer about locking down the perimeter – it’s about understanding who is accessing the information and the data they’re allowed to access.

IT needs to implement an identity-centric approach to secure data, but according to a recentPonemon study, only 29% of organizations are confident that they can authenticate users in the cloud. At first glance, that appears to be a shockingly low number, but if you think about it, how do you verify identity?

Usernames and passwords, while still the norm, are not sufficient to prove identity and sure, you can identify a device connected to the network, but can you verify the identity of the person using the device?

In a recent @CloudCommons tweetchat on cloud security, the issue of proving the identity of cloud users kept cropping up:

And then there's the issue of PRISM.

To quote Sgt. Esterhaus from Hill Street Blues, "Let's Be Careful Out There."