Tag: John Halamka

Our Cancer Journey – Week 6

Jan 26, 2012• 2

By John Halamka, MD

We’re halfway through the most challenging cycles of chemotherapy, Kathy has lost her hair, and her fatigue is getting worse but her mood is still very positive.

On Friday January 20th, Kathy received Cyclophosphamide (Cytoxan) 1200 mg, Doxorubicin (Adriamycin) 120 mg and her pre-chemotherapy supportive medications Fosaprepitant 150 mg, Dexamethasone 12 mg and Ondansetron 8 mg.

She tolerated it well.

Her Complete Blood Count shows that her Granulocyte Count has dropped from 6690 to 3610 since the chemotherapy affects her fast multiplying white cells as a side effect of targeting the cancer. Her hematocrit has fallen from 42 to 32. She tires more easily but her appetite is good. Small frequent meals enable her to overcome any GI symptoms.

We’ve been told that the Adriamycin/Cytoxan is the most difficult chemotherapy. Only two more cycles to go.

The photograph above shows Kathy and me at age 21 in our Stanford graduation photo. She’s always had long, luxuriant hair, even a waist length braid at one point.

On January 21st, her hair began falling out in clumps. It was not exactly painful, but felt very odd, as if her hair had not been washed in months and just did not lie on her scalp properly. In consultation with her cancer survivor friends, she decided to shave it off. Her hairdresser gave her a “GI Jane” cut realizing that the small hairs left will fall out soon, but in a more manageable and comfortable way. I seriously considered shaving my head in solidarity, but she asked me not to.

The Promise of Electronic Healthcare Records

Dec 6, 2011• 18

By JOHN HALAMKA, MD

Last week, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid. The nation should be grateful that such a visionary was at the helm. The nation should frustrated that he was never confirmed.

In his parting interview with the press, he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:
*Patients are overtreated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

My Non-Linear Work Stream

Sep 30, 2011• 2

By JOHN HALAMKA, MD

In the era before Blackberrys, iPhones, instant messaging, social networks, and blogs, I had a predictable day.

I could look at my week and count the meetings, lectures, phone calls, writing, and commuting I had to do.

Although my schedule was busy, I could schedule exercise time, family time, and creative time.

Today, I would not describe my work day as linear or predictable. I do as much as I can, attending to every detail I remember, and hope that by the end of the week the trajectory is positive and the urgent issues are resolved.

Here’s what I mean.

Since there are no barriers to communication, everyone can communicate with everyone. Every issue is escalated instantly. Processes for decision making no longer involve thoughtful stepsthat enabled many problems to resolve themselves. We’re working faster, but not necessary working smarter. We’re doing a greater quantity of work but not necessarily a higher quality of work.

Everyone has a mobile device and their thoughts of the moment can be translated into a message or phone call, creating a work stream of what amounts to hundreds of “mini-meetings” every day.

Lessons Learned from Steve Jobs

Aug 30, 2011• 1

By JOHN HALAMKA, MD

I recently spoke with several reporters about Steve Jobs’ impact on healthcare, thanking him for the past 15 years of innovation. In preparing for those interviews, I reviewed Steve’s career milestones,

In 1997, Apple Computer was in trouble. Its sales had declined from 11 billion in 1995 to 7 billion in 1997. Its energies were focused on battling Microsoft. It had lost its way.

Steve Jobs made these remarks at MacWorld 1997, a few months before becoming Apple’s CEO. He outlined a simple go forward plan:

1. Board of Directors
2. Focus on Relevance
3. Invest in Core Assets
4. Meaningful Partnerships
5. New Product Paradigm

How can we apply these 5 ideas to the work we’re doing in HIT?

It’s clear that Health Information Exchanges across the country are in trouble – CareSpark closed its doors, the CEO of Cal eConnectresigned, and Minnesota Health Information Exchange ceased operations.

Healthcare is Different

Aug 14, 2011• 79

By JOHN HALAMKA, MD

I’m often asked why healthcare has been slow to automate its processes compared to other industries such as the airlines, shipping/logistics, or the financial services industry.

Many clinicians say that healthcare is different.

I’m going to be a bit controversial in this post and agree that healthcare has unique challenges that make it more difficult to automate than other industries.

Here’s an inventory of the issues

1. Flow of funds – Hospitals and professionals are seldom paid by their customer. Payment usually comes from an intermediary such as the government or insurance payer. Thus, healthcare IT resources are focused on back office systems that facilitate communications between providers and payers rather than innovative retail workflows such as those found at the Apple Store.

National Strategy for Trusted Identities in Cyberspace

Apr 27, 2011• 4

By JOHN HALAMKA, MD

On April 15, 2011, the White House released the National Strategy for Trusted Identities in Cyberspace (NSTIC) during a launch event that included U.S. Sec. of Commerce Gary Locke, other Administration officials, and U.S. Senator Barbara Mikulski, as well as a panel discussion with private sector, consumer advocate, and government ID management experts.

What is it a trusted identity in Cyberspace? This animation describes the scope of the effort. It includes smartcards, biometrics, soft tokens, hard tokens, and certificate management applications.

NSTIC envisions a cyber world – the Identity Ecosystem – that improves upon the passwords currently used to access electronic resources. It includes a vibrant marketplace that allows people to choose among multiple identity providers – both private and public – that will issue trusted credentials proving identity.

Why do we need it? NSTIC provides a framework for individuals and organizations to utilize secure, efficient, easy-to-use and interoperable identity solutions to access online services in a manner that promotes confidence, privacy, choice and innovation.Continue reading…

Freeing the Data

Mar 2, 2011• 3

By JOHN HALAMKA, MD

I’m keynoting this year’s Intersystems Global Conference on the topic of “Freeing the Data” from the transactional systems we use today such as Enterprise Resource Planning (ERP), Customer Relationship Management (CRM), Electronic Health Records (EHR), etc. As I’ve prepared my speech, I’ve given a lot of thought to the evolving data needs we have in our enterprises.

In healthcare and in many other industries, it’s increasingly common for users to ask IT for tools and resources to look beyond the data we enter during the course of our daily work. For one patient, I know the diagnosis, but what treatments were given to the last 1000 similar patients. I know the sales today, but how do they vary over the week, the month, and the year? Can I predict future resource needs before they happen?

In the past, such analysis typically relied on structured data, exported from transactional systems into data marts using Extract/Transform/Load (ETL) utilities, followed by analysis with Online Analytical Processing (OLAP) or Business Intelligence (BI) tools.

In a world filled with highly scalable web search engines, increasingly capable natural language processing technologies, and practical examples of artificial intelligence/pattern recognition (think of IBM’s Jeopardy-savvy Watson as a sophisticated data mining tool), there are novel approaches to freeing the data that go beyond a single database with pre-defined hypercube rollups. Here are my top 10 trends to watch as we increasingly free data from transactional systems.Continue reading…

Regression to the Mean

Feb 25, 2011• 4

By JOHN HALAMKA

You may have heard about the Sports Illustrated Effect, the notion that people who appear on the cover of the magazine are likely to experience bad luck, failure, or a career spiral.

Over the 30 years of my own professional life, I’ve watched many colleagues become famous, receive significant publicity, then fail to live up to the impossible expectations implied by their fame. They regress to the mean. Nature seems to favor symmetry. Things that rise slowly tend to decline slowly. Things that rise rapidly tend to drop rapidly.

Fame is usually a consequence (good or bad) of invention, innovation and accomplishment. Fame itself is generally not what motivates a person to accomplish their feats. An Olympic athlete is usually inspired because of a highly competitive spirit. An inventor is usually inspired because he/she believes there is a better way. Fame that is the consequence of a feat can affect future behavior. It can become an intoxicant and motivate someone to strive for accomplishments that keep the fame coming.

I’ve thought about my own brushes with fame.

When I was 18 and started at Stanford, I realized that my scholarships would only cover the first year of tuition. I visited the Stanford Law library, read the US tax code and wrote software for the Kaypro, Osborne 1, and CP/M computers that calculated taxes. The software shipping from my dorm room generated enough income to start a small company. When the PC was introduced, we were the first to provide such software to small businesses seeking to compute their tax obligations. By the time I was 19, I moved into the home of Frederick Terman, former Provost of Stanford, and the professor who first encouraged William Hewlett and David Packard to build audio oscillators and form a new company called HP. The story of a 19 year old running a software company and living in the basement of founder of HP was newsworthy at the time. I did interviews with Dan Rather, Larry King, and NHK TV Japan.Continue reading…

Obtaining Meaningful Use Stimulus Payments

Jan 23, 2011• 4

By JOHN HALAMKA, MD

Many clinicians and hospitals have asked me about the exact steps to obtain stimulus payments.

On January 3, 2011, CMS began registering clinicians for participation in meaningful use programs. Every region of the United States has Regional Extension Centers which can help answer any questions. Here’s an overview of the steps you need to take.

1. Choose between Medicare and Medicaid programs. If you qualify, Medicaid offers greater incentives and does not require you to achieve meaningful use before stimulus payments begin.
a. To qualify for Medicaid, 30% of your patient encounters must be Medicaid patients. (20% for pediatricians)
b. To qualify for Medicare, keep in mind that meaningful use payments are made at 75% of Medicare allowable charges for covered professional services in the calendar year of payment, per the payment maximums below:

Year 1 $18,000
Year 2 $12,000
Year 3 $8000
Year 4 $4000
Year 5 $2000

Thus, a total of $44,000 is available at maximum, but could be less if your allowable Medicare charges are less than

Year 1 $24,000
Year 2 $16,000
Year 3 $10,667
Year 4 $5333
Year 5 $2667

The Proposed Stage 2 and 3 Meaningful Use Recommendations

Jan 20, 2011• 2

By JOHN HALAMKA, MD

On January 12, the Health Information Technology Policy Committee published its proposed Stage 2 and 3 Meaningful Use recommendations for public comment.

Robin Raiford from Allscripts created a Quick Guide to the recommendations, making it easy to compare Stage 1, 2 and 3 in a single PDF.

Here’s my analysis of the proposed Stage 2 and 3 criteria.

1. CPOE – Stage 1 requires more than 30% of unique patients with at least one medication in their medication list have at least one medication order entered using CPOE Stage 2 expands this to 60% of patients for at least one medication, lab or radiology order. Stage 3 expands this further to 80%. CPOE orders do not need to be transmitted electronically to pharmacies/labs/radiology departments. This is a very reasonable rate of CPOE adoption. The hardest part of implementing CPOE is getting started, which happens in Stage 1. Adding different types of transactions (without requiring electronic transmission to back end service providers) is more about workflow and behavioral change than technology change.

2. Drug-drug/drug-allergy interaction checks – Stage 1 requires that interaction technology be enabled. Stage 2 adds that it will be used for high yield alerts, with metrics for use to be defined. The idea is that many drug databases contain too many false positive interaction rules, so adoption is slowed by alert fatigue. If only high yield alerts are required (here’s what we’ve done at BIDMC ), clinicians are more likely to trust drug interaction decision support. Stage 3 adds drug/age checking (such as geriatric and pediatric decision support), drug dose checking, chemotherapy dosing, drug/lab checking, and drug/condition checking. These are all reasonable goals, but automating chemotherapy protocols is quite challenging. BIDMC built an Oncology Management System and added a full time research nurse to ensure all chemotherapy protocols are updated and accurate. It may be asking too much to require chemotherapy dosing decision support nationwide by 2015.