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."

Texas Tort Reform - Ten Years Later

From the Texas Medical Association:

... Ten years ago, TMA physicians and medical students banded together to push for passage of landmark medical liability reforms. The Medical Malpractice and Tort Reform Act of 2003, House Bill 4, went into effect Sept. 1 that year. Twelve days later, Texas voters approved Proposition 12, an amendment to the Texas Constitution that validated the legislature’s actions. HB 4 caps noneconomic damages in medical liability cases. Texas’ $750,000 total cap includes a $250,000 liability limit per physician for noneconomic damages such as pain and suffering. The tort reform act doesn’t restrict economic damages.

Since that law passed, record numbers of physicians have relocated here to care for Texas patients. Physicians already practicing here say they can recruit more specialists trained in Texas and from out of state, thanks to tort reform. In the fiscal year that ended Aug. 31, 2012, the Texas Medical Board received 4,253 medical license applications and processed 3,630. Compare that to 2003, when the board received only 2,561 applications and processed 2,513.

“Tort reform has done wonders for the state by attracting more physicians to practice here, improving access to care, and making it economically possible for physicians to continue caring for patients,” Dr. Justin Hensley said.

Read the whole thing. 

Liability Reform IS Healthcare Reform.

Ovarian Cancer Awareness Month

September is Ovarian Cancer Awareness Month. Ovarian cancer kills over 20,000 women a year. Despite often being described as a silent killer, ovarian cancer does have signs and symptoms. While there is still no universally accepted screening for this dread disease, some women at high risk, eg. BRCA 1 & 2 carriers, can discuss risk reduction surgery with their gynecologist. Moreover, oral contraceptive use may offer some protection.

For more information about ovarian cancer awareness, check out the National Ovarian Cancer Coalition website.

Changes

Having just returned from our annual I 95 Florida road trip, I prepare to embark along a new path. That's right - a new position at this stage of my life - is this a sign of maturity or early stages of dementia? Beginning next week, I will assume the mantle of Chief of Gynecological Ultrasound for the North Shore LIJ Health System. In this new era of so-called healthcare reform with its added administrative burdens, basically they made me an offer I couldn't refuse. So off I go on a new adventure, with new challenges and new responsibilities. Don't worry, though. I will still continue to post here on various topics concerning healthcare, women's health, and anything I feel is worth sharing. So please don't touch that dial.

I watch the ripples change their size
But never leave the stream
Of warm impermanence
So the days float through my eyes
But stil the days seem the same
And these children that you spit on
As they try to change their worlds
Are immune to your consultations
They're quite aware of what they're going through

Ch-ch-ch-ch-changes
(turn and face the strain)
Ch-ch-changes
Don't tell them to grow up and out of it
Ch-ch-ch-ch-changes
(turn and face the strain)
Ch-ch-changes
Wheres your shame
Youve left us up to our necks in it
Time may change me
But you can't trace time
- David Bowie

When All Else Fails, Blame The Obstetrician

Now that the vaccine-autism link has been debunked again, Jenny McCarthy notwithstanding, everything but the kitchen sink is being put forth as potential causes of this affliction. The latest out of Duke finds a connection between autism and induction of labor.

... Overall, the likelihood of autism increased by 23% in association with induced or augmented labor as compared with children whose mothers had unassisted labor, Simon G. Gregory, PhD, of Duke University, and colleagues reported inJAMA Pediatrics.

Induction only, augmentation only, or the combination all were associated with significantly increased odds of autism. The magnitude of increased risk was similar to that associated with fetal distress, meconium, prematurity, and maternal diabetes, they said.

Curiously, this linkage seemed to hold predominantly for boys. The connection for females was more tenuous.

While this is certainly interesting, remember that association hardly proves cause and effect. Emily Willingham in Forbes gives this article a thorough review and notes some quite strange findings. For one thing, moms' having a college education increase the odds of her child attending special education. Yes, you read that right. Also, maternal smoking apparently decreases the risk of later autism diagnosis. So should we infer that women should drop out of school and commence smoking? Hardly.

While the dust settles around this study, remember that there have been numerous studies linking various genetic factors and autism, the latest trumpeted by the New York Times. Here's a thought - perhaps whatever genetic or epigenetic factor which may lead to autism spectrum may also predispose to a situation which subsequently require induction of labor. 

Remember that as Mark Twain ( often attributed to Benjamin Disraeli) said, there are "lies, damned lies, and statistics." I learned in high school that statistics are like bikinis - what they reveal is suggestive but what they conceal is vital. 

When Is The Baby Due? It's Complicated

While intellectually, most expectant mom's understand that the due date is only accurate within an up to two week window, folks still want to know a specific estimated time of arrival. Now from Medpagetoday.com comes news of this research, concluding that mom's may do better with a range of dates.

... A cohort of pregnant mothers who were followed from conception to birth showed that, despite a median gestational period of 268 days, length of pregnancy varied by 37 days even after excluding mothers who gave birth preterm, according to Anne Marie Jukic, PhD, of the Epidemiology Branch of the National Institute of Environmental Health Sciences in Durham N.C., and colleagues.

Factors affecting length of pregnancy included length of time to conception, rate of progesterone rise, the mother's age, birth weight, and length of pregnancy in previous births, they wrote online inHuman Reproduction.

The authors noted that despite an estimated pregnancy period of 280 days from the mother's last menstrual period routinely assigned to mothers, only 4% of pregnancies fall on that date, while 70% occur within 10 days of that estimate "even when the date is estimated by ultrasound."

Here's what I've learned from my patients - nobody seems to worry if the baby arrives a week early. But one or two days late is quite a different story. There's also evidence to suggest that the medical equivalent of eviction proceedings aka induction of labor at 41 weeks results in fewer Cesareans and better perinatal outcomes than just waiting. Of course you won't know when 41 weeks is reached unless you know a due date.

Finally, as I tell my patients, due dates are like train schedules. Just because the train is expected doesn't mean that's when it pulls into the station.

Hysterectomy? What About the Ovaries?

Hysterectomy is one of the most common surgeries performed in the US. Many women have a hysterectomy prior to menopause, bringing up an important issue - what about the ovaries? The answer to this question is not always an easy one.

It was not that long ago that most medical authorities urged that if a woman were over 40 years old, ovaries should be removed at the time of hysterectomy. The reasons were twofold - that ovarian cancer was too difficult to diagnose so removal would prevent a dread disease and also, that the risk of subsequent surgery for benign disease was significant. Moreover, hormone therapy would ameliorate some of the side effects of removal.

Today, the pendulum has shifted. For premenopausal women, the ovaries produce hormones which have incredible benefits - protection against heart disease and bone loss being two. Oophorectomy may also affect mental health and sexuality. Moreover, ovarian removal causes acute onset of menopausal symptoms. While estrogen administration is surely helpful, it turns out that a patient compliance is often an issue with many women simply ceasing to take the medication long term - human nature.

What about cancer? Again, the risk of subsequent ovarian cancer for most women is about 1.4 %. This drops even further with a history of pregnancies and use of oral contraceptives.

The risk of subsequent surgery is also lower, especially with the improved resolution of transvaginal ultrasound, allowing many asymptomatic benign entities to be followed.

What about the older woman? Even here, the evidence for ovarian removal is not clear cut and ovarian conservation should be an option.

There is one asterisk - the woman with a strong family history of breast and/or ovarian cancer. Here, the woman may carry a BRCA mutation and genetic counseling is advised. Those who carry such a mutation are the exceptions for whom risk reductive removal of the tubes and ovaries would be strongly advised.

OBG Management  has a useful algorithm:

I'm quite certain that with further advances in diagnosis and therapy, management will be tweaked further. Stay tuned.