By MARTIN SAMUELS, MD

In order to understand the concept of pain and its relationship to the current opioid crisis, it is prudent to review the neurology of pain an why it exists.  Several concepts are important to integrate.

Nociception:  Nociception is the capacity to sense a potentially tissue damaging (noxious) stimulus.  To illustrate this one should place a forefinger in a glass of ice water and determine how long passes until an unpleasant sensation arises.  If one performs this experiment in a large group, one can recognize that, although the stimulus is the same (a glass of ice water), the sensation arises at different rates in different people. 

In fact, a bell shaped curve will describe the distribution in any population of people.  Within 30 seconds almost all will have perceived an unpleasant sensation that is known at pain.  Nociception is a very primitive sensation. 

It is present in virtually all animals, even those without a brain, such as Aplysia, the sea slug.  Though it lacks a brain, it has nerves  and ganglia that allow it to sense and move away from a noxious stimulus.  Nociception is absolutely essential to our survival and well-being.  Without it, one would suffer tissue damage and ultimately death.  The human disease, leprosy, is a salient example of an infection that destroys the nerves that are responsible for nociception.  That lack of nociception is what causes all of the disfigurement that is characteristic of leprosy.  Anyone who has had a dental anesthetic is aware that one can inadvertently bite one’s own lip until the anesthetic wears off.

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By HAYWARD ZWERLING, MD

I have been in the health information technology field since 1990 when I began creating ComChart EMR. It was a labor of love which ultimately evolved into a small business. From 2004 until 2012, ComChart EMR had amongst the highest KLAS rating of all EMRs in the small ambulatory care group. From 2011 until 2015, ComChart EMR was certified by the ONC for Meaningful Use Stage I. Unfortunately, the technical requirements arising from Meaningful Use mandates and changes in market conditions required that I stop selling ComChart EMR in 2015.

As a result of the 2.5 decades I spent creating ComChart EMR, I have learned a lot about which features are useful in the exam room and how to design an EMR so that it facilitates the user ability to provide medical care to their patient. As Judy Faulkner, Founder and CEO of Epic said, “Good software is art.” To this, I would add that it is only possible to create a well designed EMR if a practicing physician is intimately involved in both design and programming of the EMR.

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By ROBERT MCNUTT, MD

I usually walk from the University of Illinois, campus to Union Station at the end of my workday. But, that day it was raining. So, I hailed a cab. The cab driver was not in a mood to talk so I had time to relax and look around at the traffic. To my right was a recent model Mercedes sedan. I watched it for a moment and then pivoted to peer to the left. An old Toyota Corolla with the rear view mirror attached with duct tape was neck-in-neck slowed on the road with the cab and the Mercedes.

This image struck me; three impressively different cars depicting, perhaps, personal preferences and different opportunities of individuals, despite the differences, were driving on the same road.

So, this piece is about civil rights. Everyone who gets ill deserves the same road to drive on, but presently, some get better, or different roads than others. The “road” in the potentially obscure metaphor is the road that allows every individual the equal and omnipresent rights to information that will allow them to make an informed decision.

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By JOHN HALAMKA

When my father died 3 years ago,  my comments at his funeral  noted  that the greatest aspiration any of us can have is to make a difference in the world.  My father’s life made a difference.

I’m always self critical and analyzing my own life.  I moved to Boston 20 years ago this month.   In those 20 years of service to BIDMC, Harvard, numerous federal organizations,  international governments, and industry, I’m hopeful that I’ve laid a foundation for 20 more years of trying to make a difference.  It’s hard to forecast the best path to have an impact on the healthcare ecosystem, but I can try.

The past 5 years belonged to government – with $34 billion spent on healthcare IT as a result of HITECH, the Meaningful Use program accomplished the goal of moving clinician practices and hospitals from paper to digital systems.    Although many challenges remain – improving workflow, enhancing quality/safety, and ensuring usability, the basic platform on which we can build future innovation has been created.

The government will continue to be very a important actor, especially CMS,  setting payment policy that will impact the behavior of all stakeholders.  However, I believe the era of prescriptive government direction of the IT agenda has ended.  Provider organizations are begging for an outcomes focus, instead of a process focus.

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By STEVEN FINDLAY

One of the things that needs to happen as physician payment reform and EHR interoperability (post-meaningful use) evolve under MACRA is this:  CMS and ONC need to promote, measure and significantly enhance consumers’ access to their health information and/or interaction with EHRs.   

Stated another way: after spending $30 billion to compel the adoption of EHRs, the federal government needs to get its act together to assure that consumers and patients are directly—and not just indirectly—benefiting.  That was, after all, part of the original vision way back in the George W. Bush administration.  Simply stated:  Electronically stored and continually updated information and records on you should be available to you.   And without a lot of trouble.   Continue reading…

CECI CONNOLLY

Nearly every morning lately, as I make my daily dart to the metro station two blocks away, I pass a familiar face. She is one of about a dozen women who toil in the local nail salon. She does not live in my neighborhood, yet I see her early most mornings hiking up our hill, long before the salon opens.

Most days I wave and smile. But one recent morning I stopped and asked what she was doing. Her English is so-so and my Vietnamese is non-existent. But she managed to proudly convey, “Ten thousand steps!”

She’s not the only one. I myself have caught the walking bug, egged on by my better half and a Fitbit. For me, the rubber wristband has been revelatory. Given how active I am, I just assumed I was getting 10,000 steps every day. Far from it. Knowing your count – and how far you are from the daily goal – is an effective nudge to get off the metro one stop early or choose a lunch spot that’s a few blocks further away.

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By DAVID INTROCASO

This past April 8th federal prosecutors made known former Republican House Speaker, Denis Hastert, sexually molested at least four boys while employed as an Illinois high school wrestling coach beginning in the 1960s.  Prosecutors said there was “no ambiguity” about these abuses.  They were, they said, “known acts.”1 While the news was disturbing sexual and all other forms of child abuse is commonplace.  According to the Centers for Disease Control’s (CDC) Adverse Childhood Experiences (ACE) study, one in four girls and one in six boys are sexually assaulted before they reach the age of eighteen.2  It cannot be a surprise therefore that even a member of Congress molested young boys. 

Also not surprising is how frequently child abuse, if made known, is not revealed until many years later.  Rumors about Hastert’s behavior persisted for years, for example, they were floated during 2006 when Congressman Mark Foley was forced to resign for forwarding soliciting e-mails and sexually suggestive instant messages to teenaged boys.  It was not until last year Hastert’s actions nearly fifty years ago became known albeit accidentally.  What banking officials and eventually the FBI wanted to learn, pursuant to the PATRIOT Act and other federal laws, was why Hastert made multiple $50,000 bank withdrawals over two years.  Hastert initially told officials he was buying vintage cars and stocks.  He then explained he did not think banks were safe and then argued he was the victim of extortion.  None of these explanations were true.  Eventually, the FBI learned Hastert was paying a victim for his silence. 

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