Telemedicine for Orthopedics

Orthopedics may be an opportunity for telemedicine. It may be especially useful in the correctional center setting where travel time for an orthopedic physician mY be an inefficient use of a valuable resource. See the abstract below:


Outpatient Orthopedics and the Impact of Telemedicine Upon Costs and Patient Care
Richard M. Garden, MD

Utah Department of Corrections, P.O. Box 250, Draper, UT 84020. Phone: (801) 576-7100.rgarden@utah.gov

In an effort to investigate and evaluate a start-up telemedicine program, the first two years of conducting orthopedic clinics via telemedicine were analyzed. These years were compared to the last full year during which all such clinics were conducted off site. The numbers of off-site visits, surgeries, total visits, grievances (patient complaints), and costs associated with on-site telemedicine (telecasts) were compared for years 1997, 1999, and 2000. A major reduction in the need for off-site visits, a small change in costs, a small increase in total utilization, a decrease in orthopedic-related grievances, and minimal changes in the number of surgeries were found. It was concluded that telemedicine is a fruitful endeavor and also offers a few less tangible benefits and lessons learned.

Journal of Correctional Health Care, Vol. 9, No. 1, 53-61 (2002)
DOI: 10.1177/107834580200900106

Providers skeptical of meaningful use reimbursement process

Providers skeptical of meaningful use reimbursement process"Under a draft of potential measures released in September by the HIT Policy Committee, eligible providers would have to use CPOE (computerized physician order entry) for all orders, implement drug-drug, drug allergy and drug-formulary checks and maintain an up-to-date problem list of current and active diagnoses based on ICD-9 or SNOMED.
"

The issue of interoperability with hospitals in the local community is essential:
"...physicians from small practices often interact with more than five community hospitals and several labs, each with a different system. Doctors need to know that whatever electronic health record they buy will work with the systems the labs and hospitals have."

WSJ: Video conferencing in Medicine

More Hospitals Are Using Video to Connect Patients With Specialists Far Away, Speeding Treatment

see the WSJ article here.

Guest Post: Clinical Process in Pain Management

Clinical Process in Pain Management
It’s definitely not easy when you know you have a terminal disease like cancer. What’s worse is the fact that you know you’re going to suffer a painful death, one that will not come quickly but is drawn out and excruciating. Pain management is thus a very important part of palliative care, the kind that is provided to people who have been given just a few months to live at best, people who have lost all hope and for whom chemo and other treatment options are no longer effective. Even those patients who see a sliver of hope in the form of radiation and chemotherapy are in pain, because for this dreaded disease, even the treatment is a form of unbearable pain.
The clinical process in pain management includes the following steps:
• Assessing the pain and documenting its aspects – like how bearable it is and where it originates, if it is radiating or localized, if it is continuous or sporadic, and so on.
• Recognizing the triggers of pain – identifying the factors that cause the pain to flare up or intensify is important because it helps minimize trauma.
• Finding the cause of the pain – the triggers for the pain may be different from the cause. The cause may be a broken bone, but the trigger may be someone touching the injured area or moving it. It is imperative that the cause is identified and treated if the pain must be stopped for good.
• Assessing the risk in the situation – some treatment methods fail to take into account the risks involved. It’s important to assess all the risks, especially when treating people with prior medical conditions.
• Devising a care plan to manage the symptoms of pain – this is especially important when you’re looking after terminally ill patients who need long term pain management plans if they are to live out their last days in relative comfort.
• Treating the cause of the pain – the cause of the pain must be treated if possible, like in the case of broken bones or torn ligaments.
• Considering alternative action when the patient is unresponsive to one method of management – people respond differently to different drugs, so each person’s care plan has to be formulated with precision.
• Dealing with adverse drug reactions – some patients may be allergic to certain drugs, so you must ask the right questions before you begin treatment or pain management therapy.
• Continuously monitoring the situation to see if there has been any improvement – the patient has to be watched for signs, both of improvement and relapse. It’s important that non-verbal cues like grimaces and frowns be taken into consideration as well when caring for patients who are very ill.
Pain management is important in not just cancer but also in post-surgery situations and in acute care conditions. And when the clinical process is efficient, it makes it that much more bearable for the patient.


This guest article was written by Adrienne Carlson, who regularly writes on the topic of nurse practitioner schools . Adrienne welcomes your comments and questions at her email address: adrienne.carlson1@gmail.com

EHR Killer App

Great, insightful article on the need for a EHR Killer App:

"...So where is the EHR 'killer app'? Unfortunately, it doesn't yet exist, and instead providers find themselves courted by innumerous EHR vendors, each offering their own, proprietary methods for accomplishing familiar tasks. If providers aren't careful, they might find themselves locked into vendor-specific software systems and siloed IT universes."

HITECH and its effect on HIT

An interesting article on how HITECH has its own set of unintended consequences. In this case, the government can "screw things up" by forcing providers into acquiring HIT systems at a such a fast rate (less than 24 months), that they end up buying " certified" systems by large vendors. The result being they end up with systems that are less innovative with poor usability. This is a sure way to stiffle HIT innovation and destroy entrepreneurship. And then we wonder why HIT systems are so primitive compared with systems in other industries. Remember, Meditech introduced the ability to point-and-click by a mouse only within the last 5-7 years. This article does a great job in explaining this:

Mapping Lab terminologies

There can be anywhere from 5000 to 15,000 labs code at a given institution. The task of mapping these codes to a standard code set to another institutions codes for the purposes of use in Health Information Exchanges, EHRs for trending lab results can be daunting.

This task cannot be done by someone who understands just the bits and bytes. Considerable domain knowledge is required in order to this efficiently as well as accurately. It is common knowledge within this domain that far fewer than the 5000-15,000 codes account for the vast majority of the commonly ordered tests. And among this subset of commonly ordered, a smaller number of codes are actually important for the purposes of trending.

For example, in the in patient setting, each morning during review of patients lab during rounds, the most commonly trended lab observations are the lab elements contained within the "Comprehensive and Basic Metabolic" profiles, and the CBC. The CPK and ESR rates are trended, but usually for a limited time duration within a patients hospital stay. Test such as the Rheumatoid Factor or ANA on the other hand do not typically require a trended analysis for clinical decision making.

This paper by Daniel Vreeman et al (Regenstrief Institute, Inc. and Indiana University, Indianapolis, IN) makes the following conclusion:

"Given limited mapping resources, our findings support the strategy of focusing the effort on the small subset of observations that account for the majority of volume. Mapping the observation codes that cover 99% of the reported results would ensure that all of the results for more than 99% of patients would be mapped. Mapping even the few (49 to 68) observation codes accounting for 80% of reported results would cover all results for 91–98%
of patients."

Also see: Automated Mapping of Observation Codes Using Extensional Definitions

Hospital 30 day Re-Admission Rate now reported by CMS

The CMS website will now report on hospital's 30 day re-admission rates along with mortality data. Read more here. These measures are felt to be an indication of a hospital's quality of care. Hospitals will need to find ways to minimize repadmissions while at the same time, keeping lengths of stay low. This means, the post-hospitalization phase needs to be managed effectively, employing technologies such as telemedicine and remote monitoring.

Nursing Home Telemedcine

There has been considerable work in this field for a number of years. Lack of payer reimbursement, especially Medicare, has hindered the growth of nursing home telemedicine, preventing it from being a self-sustaining service. As a result, most applications have been grant funded. Medicare is now reimbursing this service for rural communities , and there is a bill in congress which would expand coverage to the entire country without regard to rural designation status.

I have listed below, links documenting the development of telemedicine in nursing homes:

Employing a Wireless Mobile Solution to Bring
Telemedicine to the Nursing Home Bedside

12/14/2008: Medicare will now pay for nursing home patients to be treated by telemedicine

University of Iowa Hospitals and Clinics, Family Medicine Department: Nursing home telehealth system

Dan Gunderson, Minnesota Public Radio

December 12, 2008 : Medicare will start paying for telemedicine

April 7, 2003: West Texas Rural Nursing Home Telemedicine Network Project-planned

“Direct Telemedicine in a Nursing Home Setting” Rationale – Innovation - Feasibility. Louis Lareng, Monique Savoldelli, Pierre Rumeau

Nursing Home Telemedicine- our latest presentation

See www.clinicore.com

Massachusetts Healthcare/IT related Bills

Massachusetts Healthcare/IT related Bills:


An Act to Promote a Statewide System for Chronic Care Management to Improve Health Care Quality and Contain Costs

Documents & Status: Text of Senate 1279 | Status

If Massachusetts is to contain costs of Medicaid and of the new Health Care Access Reform law without sacrificing quality of care, improved management of individuals with chronic health conditions is essential. The best management of chronic care relies on linkage with technology systems. This bill would establish a statewide strategy for chronic care management. Such a strategy would use the eHealth initiative to develop a chronic care infrastructure, prevention of chronic conditions, and chronic care management program. It would also establish the Chronic Care Management Program in the Executive office of Health and Human Services to promote collaborative strategies for managing chronic diseases among health care professionals and insurers.

See text of the Bill.

Telemedicine Studies

Telemedicine via video conferencing is comparable to face-to-face doctor-patient encounters:

Study finds virtual doctor visits satisfactory for both patients and clinicians, May 2009 issue of the Journal of Telemedicine and Telecare
"There is growing evidence that the use of videoconferencing in the medical environment is useful for a variety of acute and chronic issues," says Ronald F. Dixon, MD, an internist at Massachusetts General Hospital
"Videoconferencing between a provider and patients allows for the evaluation of many issues that may not require an office visit and can be achieved in a shorter time."

Benefits of Telemedicine for Stroke care in ERs

New evidence demonstrating the benefits of telemedicine based stroke care is cited in the recent Journal of the American Heart Association.
The current physician shortage, is creating new opportunities for showing telemedicince's value.

Stroke care is a narrow application for telemedicine. The use of TPA treatment for acute stroke and the need for an urgent evaluation of a stroke patient within 1-2 hours in order to administer TPA for the treatment an acute stroke has created a market for telemedicine for stroke care.

Hospital emergency rooms already have a dificult time finding neurology coverage. The need to have a neurologist available to make a thorough patient evaluation within 1-2 hours of an impending stroke has exacerbated the shortage. As a result, hospitals have been willing to pay for this service even though there is no payer coverage, including Medicare.

The benefits of telemedicine do not stop with stroke care. Any situation or setting where there's a paucity of phyician access, is ideal for telemedicine. We have found that nursing homes are such a setting. There are too few physicians following too many nursing homes. Telemedicine can solve this problem. See Fierce HealthIT for more.

INTERACT: Reducing avoidable hospitalization of Nursing homes

Here are some presentations from the Care Transition Conference held recently this past April in the Boston area. There was a presentation on reducing hospital readmission from nursing homes.
The INTERACT project concluded that effective communications and the use of disease specific protocols are essential for reducing readmission rates. On site physician availability was also specifcally mentioned as beig another critical factor.

Care Transitions
Re-admit in Nursing homes

INTERACT - Reducing Avoidable Hospitalizations of Nursing Home Residents

Connected Health Framework

Microsoft's "vendor agnostic" architecture for healthcare applications.
New version: Microsoft Connected Framework version 2

This set of documents details an approach for designing interoperable health care applications using a Service Oriented Architecture or SOA. There is a lot of sophisticated health care domain knowledge contained within this document set, which tells me that Microsoft has done their homework, My guess is that Microsoft is working on a universal healthcare development platform. Sort of like a "Healthcare development operating system" on which to build all other healthcare applications. They started this approach already with Healthvault.

Telemedicine Legislative Watch

House Resolution 2068: Medicare Telehealth Enhancement Act,
This bill will expand mediciare reimbursement to urban and suburban area. Currently telemedicine reimbursement is limited to rural areas, which essentially excludes 80% of the population.

Telemedicine has been shown to increase access to healthcare. This is especially important given the current physician shortage. Used effectively, telemedicine can improve efficiency and reduce costs. It also has the potential to improve quality, especially in reducing re-admissions, avoiding needless emergency room visits and inpatient admissions. This bill may actually help in making telemedicine more mainstream.

Nursing HomeTelemedicine Videos

We have put together several videos demonstrating the use of telemedicine in the care of nursing home patients:

Reducing 30 day Hospital Readmission rates

The Institute of Healthcare Improvement or IHI, has launched a grant funded initiative for reducing Rehospitalizations. It is supported by the Commonwealth fund. The goal is to reduce the 30-day rehospitalization rate by 30%. Another stated goal is to improve patient and family satisfaction with transitions of care and with the coordination of care.

IHI recommends these 4 elements at the time of hospital discharge:

1. Enhanced assessment of post-discharge needs;
2. Enhanced teaching/learning;
3. Enhanced communication at discharge; and
4. Timely post-acute follow up

IHI states that success is dependent on active partnerships with providers across the continuum of care: hospitals, skilled nursing facilities, home health, ambulatory settings and patient/caregiver.

The focus of this project will have implications in healthcare payment reform, so it will be important to follow the progress of this project. There's a strong emphasis on improving care transitions and to identify those important services that will enhance this process. Unfortunately, many of these services are currently not reimbursed. It will require an out-of-the-box thinking beyond the current fee-for-service payment model in order to finally develop solutions that really work.

WSJ writes about the perils of an EMR stimulus

From the opinion page of the WSJ from April 14, 2009: "A competitive marketplace would produce the most innovative medical-records system"

I wrote earlier about the dangers of having the government force physicians into buying the "right" EMR systems. That is, systems approved or certified by the government, possibly CCHIT certification. This may have the unintended consequences of stifling competition and innovation. Can you imaging if the government had mandated that all businesses use a "certified" word processing system or a "certified" search engine? If this was the case, we'd all be using a Wang word processing system and Google may never have been created.

The WSJ puts it very nicely in this opinion piece:

"The ideal system would be an open platform for many developers to write applications that are allowed to succeed and fail, much like Apple's iPhone software. They argue that the key is "allowing competition and 'natural selection' for high-value, low-cost products."

"The stimulus hands the Obama Administration the power to define and approve "certified" records, therefore the power to create a health-tech monopoly. With stimulus money being shoveled out as quickly as possible, doctors and hospitals may end up prematurely investing in the costly systems that happen to have the government seal of approval -- and in the process freezing out an innovative marketplace."

Medicare Reform: Denying payment for 30 day re-admissions

Connected Health: Expanding its Role to Prevent 30-day Hospital Readmissions

Friday, August 22, 2008 | Allison McDonough, MD

Dr McDonough makes the following Points:

• "Connected health can contribute significantly to preventing such readmissions by improving monitoring of patients after discharge."
• "May provide additional benefit by assisting with access to timely ambulatory care for high risk patients."
• "There is ample room for improvement in 30 day readmission rates."

• "In 2005, an average of 18% of patients were readmitted within 30 days of their hospital discharge, with a range of 14% at the 10th percentile to 21% at the 90th percentile (Commonwealth Fund National Scorecard on U.S. health system performance, 2008)."
  
• "Medicare estimates that 13% of these readmissions were “potentially avoidable,” based on the IPPS rule, with major areas of concern including poor communication with patients at discharge, especially around medications, and inadequate post hospital discharge monitoring."
• "Prevention of these avoidable readmissions could save Medicare about $12 billion per year. (Report on Medicare Compliance, Volume 17, Number 24, June 30, 2008)"

• "Post Hospital Discharge Monitoring: Remote daily measurement of vital signs and symptoms in the heart failure population has shown great promise already in reducing readmissions, through improved monitoring as well as patient education."
  
• "IT platforms which facilitate interactions with Primary Care Providers will enhance the effectiveness and efficiency of telemonitoring."
  
• "These interactions may also improve patients’ access to timely ambulatory care, avoiding Emergency Department visits and readmissions."

Great comments made by some readers:

"I would like to also suggest hospital/physician referral's to Skilled Nursing Facilities. Many people still have the idea that a "Nursing Home" is the end of the road of life, however this is no. Most SNF's can handle much higher levels of care post-acute and most offer wonderful rehab programs and all disciplines (PT, ST, OT). It would be nice to develop a "circle" of care. From Hospital to SNF and then home with home health. This would really help deter the emergency room visits and the costs asscoiated with such visits. Also, a way to educate about the Medicare 30 day window, post hospital stay, for patients and the hospital staff would be very beneficial. Most of the hospital case managers and ER staff are not aware of this benefit."
Posted by: Robin Davis



Comments by the Author: Allison McDonough, MD

• "There is clearly a vital role for the visiting nurse in caring for our sickest patients. SNF and Rehab facilities are also an essential part of the continuum of care. However, as you know, many very sick or complicated patients are still not homebound, and do not qualify for VNA services. I see connected health as one way to fill this gap."
• "...dangers patients face in periods of transition, e.g. hospital or SNF to home."
  
• "Research from Kaiser found that >90% of hospital discharge medication lists contained errors (such as duplicative medication classes, interactions, inappropriate dosing)."
  
• "Patients often feel, and sometimes are, abandoned."
  
• "Economic incentives to discharge early mean that patients are frequently sent home while they are still fairly ill."
  
• "we need to embrace the patient and guide them through the entire continuum of their care"

Nursing Home Care- A Literature review

Here are some interesting articles highlighting some problems related to lack of physician availability to care for nursing patients in the current health care system.

Although this is a blog with a primary focus on health IT, it is important to have a clear understanding of the problems faced by practitioners in order to create an IT solution.

I have listed some key information from my literature search

..."the quality of care in nursing homes remains inconsistent and in many respects suboptimal."
(11. Scanlon WJ. Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline. Testimony before the Committee on Finance, U.S. Senate, GAO 03-1016T, 17 July 2003)


A case for Nursing Home Physician Specialists in the Annals of Internal Medicine, March 2009

Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes (36–38).

Nursing home practice is only 4% of work time among the 20% of physicians who practice in a nursing home, one third of whom are internists (12). Often rooted in reality, perceptions among nursing home physicians of excessive regulation, paperwork, professional liability, and lack of nursing support remain barriers to developing a widespread nursing home specialist culture (13). Perhaps more important, many physicians still find it difficult to overcome logistic challenges (for example, caring for a sufficient number of patients while traveling from one facility to another), even though reimbursement for nursing home visits has increased. Without salary derived from administrative duties associated with being a medical director, many practitioners find nursing home care untenable. Waning interest in primary care and geriatrics (14), coupled with few credible role models (15), further constrains physician involvement in nursing homes. In a survey of graduating residents, fewer than 15% felt "very prepared to provide nursing home care" (16). .

1997 Study on Nursing Home Medical Practice

RESULTS: Most (77%) physicians reported spending no measurable time caring for nursing home patients

CONCLUSIONS: With increasing numbers of older and frailer residents, nursing homes will continue to be integral components of the future healthcare system. However, physicians currently spend minimal time caring for nursing home patients, with physician characteristics best predicting involvement. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide sufficient quality care for nursing home patients in an evolving health care system.

Physician involvement in nursing home patient care is important in decreasing needless hospital admissions and in improving outcomes:

"Physician care positively influences residents' hospitalization rates, functional status, and satisfaction (33–35). Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes"

EMR and the Stimulus Bill

There are many opinions regarding the effects of a government subsidy for EMR adoption. As I blogged earlier, my fear is this may just end up promoting older technologies and "establishment" vendors, potentially preventing smaller, innovative players from entereing the market. There also implications for open source EMR community as well.

Austin Merritt has some interesting thoughts in his article, Get Ready for EHR Failures, But Don’t Blame the Software.
He expresses concern that a free or overly subsidized EMR will not lead to meaningful use by physicians since people tend not to value somthing they did not pay for. I generally agree with this premise. However, if the "free EMR" is trully indispensible to the physician in terms of efficiency, workflow, care quaility, and is easy to use, then it will not matter if the EMR is free- it will be adopted by phyicians.

Addressing Long Term Healthcare worker shortage

Legislation H.R. 468 was introduced in order to expand opportunities for long term care workers to obtain additional training and education in care of our growing geriatric population. It is now well known that there will be a shortage of physicians and nurses in the near future, especially in long term care.
There's a need to widen the educational opportunities for the existing pool of long term care providers.

I'm looking for practical examples of the implications of this bill. Hopefully we will see more educational programs being offered to our nursing homes. Nurses in these facilities are over burdened by the increased complexity of today's long term care patients and often lack clinical support. Educational programs for nurses that can be offered on site at nursing homes in the practical aspects of patient care would be of great value.

Perhaps telemedicine can help fulfill this need by bringing experts remotely via video conferencing to the nursing homes and allowing all facilities equal access to quality education despite their location.


Below is an excerpt from the bill describing their findings:

Text of H.R.468 as Introduced in House

Retooling the Health Care Workforce for an Aging America Act of 2009

SEC. 2. FINDINGS.

Congress finds the following:CommentsClose CommentsPermalink

(1) The United States will not be able to meet near-term demands for chronic, geriatric, and long-term care without a workforce that is prepared for the job.CommentsClose CommentsPermalink

(2) Between 2005 and 2030, it is estimated that the number of adults aged 65 and older will almost double from 37,000,000 to over 70,000,000, increasing from 12 percent of the population of the United States to almost 20 percent of the population.CommentsClose CommentsPermalink

(3) Because the overall size of the population of older adults in the United States will increase rapidly, the number of older adults in the United States who are disabled will soar in the coming decades. Between 2000 and 2040 the number of older adults who are disabled will more than double, increasing from an estimated 10,000,000 to an estimated 21,000,000.CommentsClose CommentsPermalink

(4) A 2008 report by the Institute of Medicine of the National Academies, entitled, ‘Retooling for an Aging America’ concludes that the health care workforce will lack the capacity, in both size and ability, to meet the needs of older patients in the future unless action is taken immediately.CommentsClose CommentsPermalink

(5) Inadequate training in geriatrics, gerontology, chronic care management, and long-term care is known to result in misdiagnoses, medication errors, and inadequate coordination of services and treatments that result in poor care and is costly for the health care system as a whole.CommentsClose CommentsPermalink

(6) Currently, only 1 percent of all physicians (approximately 7,000) in the United States are certified geriatricians, even as the population of older adults is on track to double by 2030.CommentsClose CommentsPermalink

(7) Inadequate amounts of time devoted to geriatric training are reported by 1/4 of graduating medical students, and close to 1/2 of graduating medical students say they are unprepared to care for residents in nursing homes.CommentsClose CommentsPermalink

(8) Less than 1 percent of all nurses are certified gerontological nurses. Absent any change, by the year 2020, the total supply of nurses in the United States is projected to fall 29 percent below requirements, resulting in a severe shortage of nursing expertise relative to the demand for care of medically complex, frail older adults.CommentsClose CommentsPermalink

(9) Estimates suggest that there are currently only 700 practicing geropsychologists in the United States, falling far short of the current need for 5,000 to 7,500 geropsychologists.CommentsClose CommentsPermalink

(10) The Bureau of Labor Statistics of the Department of Labor predicts that personal or home care aides and home health aides will represent the second and third fastest-growing occupations between 2006 and 2016. Yet personal or home care aides are not subject to any Federal requirements related to training or education, and States have very different requirements for personal or home care aides.CommentsClose CommentsPermalink

(11) Research shows that inadequate training is a major contributor to high turnover rates among direct care workers and more training is correlated with better staff recruitment and retention rates.CommentsClose CommentsPermalink

(12) An estimated 44,000,000 family caregivers are being asked to provide increasingly complex medical services to frail and elderly loved ones wishing to live at home. Multiple surveys have documented that basic training and access to other targeted services are necessary for family caregivers to provide


See also for more information:

Bill would expand education, training for workers in LTC

Democrats file bill addressing geriatric provider shortage



See below for Information of Geriatric Education Centers (taken from above H.R.468)

TITLE I--AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACTCommentsClose CommentsPermalink

Subtitle A--Health Professions Education Related to GeriatricsCommentsClose CommentsPermalink

SEC. 101. GERIATRIC EDUCATION CENTERS.

Section 753 of the Public Health Service Act (42 U.S.C. 294) is amended by adding at the end the following:CommentsClose CommentsPermalink

‘(d) Grants To Expand and Improve Geriatric Education Centers-CommentsClose CommentsPermalink

‘(1) IN GENERAL- The Secretary shall award grants or contracts under this subsection to entities that operate a geriatric education center pursuant to subsection (a)(1).CommentsClose CommentsPermalink

‘(2) APPLICATION- To be eligible for an award under paragraph (1), an entity described in such paragraph shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.CommentsClose CommentsPermalink

‘(3) USE OF FUNDS- Amounts awarded under a grant or contract under paragraph (1) shall be used to--CommentsClose CommentsPermalink

‘(A) carry out the fellowship program described in paragraph (4); andCommentsClose CommentsPermalink



‘(B) carry out 2 of the 3 activities described in paragraph (5).CommentsClose CommentsPermalink

‘(4) FELLOWSHIP PROGRAM-CommentsClose CommentsPermalink

‘(A) IN GENERAL- Pursuant to paragraph (3), a geriatric education center that receives an award under this subsection shall use such funds to offer short-term intensive courses (referred to in this subsection as a ‘fellowship’) that focus on geriatrics, chronic care management, and long-term care that provide supplemental training for faculty members in medical schools and other health professions schools with programs in psychology, pharmacy, nursing, social work, dentistry, public health, or other health disciplines, as approved by the Secretary. Such a fellowship shall be open to current faculty, and appropriately credentialed volunteer faculty and practitioners, who do not have formal training in geriatrics, to upgrade their knowledge and clinical skills for the care of older adults and adults with functional limitations and to enhance their interdisciplinary teaching skills.CommentsClose CommentsPermalink



‘(B) LOCATION- A fellowship shall be offered either at the geriatric education center that is sponsoring the course, in collaboration with other geriatric education centers, or at medical schools, schools of nursing, schools of pharmacy, schools of social work, graduate programs in psychology, or other health professions schools approved by the Secretary with which the geriatric education centers are affiliated.CommentsClose CommentsPermalink



‘(C) CME CREDIT- Participation in a fellowship under this paragraph shall be accepted with respect to complying with continuing medical education requirements. As a condition of such acceptance, the recipient shall agree to subsequently provide a minimum of 18 hours of voluntary instructional support through a geriatric education center that is providing clinical training to students or trainees in long-term care settings.CommentsClose CommentsPermalink

‘(5) ADDITIONAL REQUIRED ACTIVITIES DESCRIBED- Pursuant to paragraph (3), a geriatric education center that receives an award under this subsection shall use such funds to carry out 2 of the 3 activities:CommentsClose CommentsPermalink

‘(A) FAMILY CAREGIVER TRAINING- A geriatric education center that receives an award under this subsection shall offer at least 2 courses each year, at no charge or nominal cost, to family caregivers that are designed to provide practical training for supporting frail elders and individuals with disabilities. The Secretary shall require such Centers to work with appropriate community partners, including family caregivers and family caregiver organizations, to develop training program content and to publicize the availability of training courses in their service areas. All family caregiver training programs shall include instruction on the management of psychological and behavioral aspects of dementia, communication techniques for working with individuals who have dementia, and the appropriate, safe, and effective use of medications for older adults.CommentsClose CommentsPermalink



‘(B) DIRECT CARE WORKING TRAINING- A geriatric education center that receives an award under this subsection shall offer at least 2 courses each year to certified nurse aides, home health aides, personal or home care aides and other types of direct care workers on ‘best practices’ for working with frail elders and individuals with disabilities, including individuals with dementia, urinary incontinence, and problems with balance or mobility, and raising awareness of medication issues for older adults.CommentsClose CommentsPermalink



‘(C) INCORPORATION OF BEST PRACTICES- A geriatric education center that receives an award under this subsection shall develop and include material on depression and other mental disorders common among older adults, medication safety issues for older adults, and management of the psychological and behavioral aspects of dementia and communication techniques with individuals who have dementia in all training courses, where appropriate.CommentsClose CommentsPermalink

‘(6) TARGETS- A geriatric education center that receives an award under this subsection shall meet targets approved by the Secretary for providing geriatric training to a certain number of faculty or practitioners during the term of the grant, as well as other parameters established by the Secretary, including guidelines for the content of the fellowships.CommentsClose CommentsPermalink

‘(7) AMOUNT OF AWARD- An award under this subsection shall be in an amount of $150,000. Not more than 24 geriatric education centers may receive an award under this subsection.CommentsClose CommentsPermalink

‘(8) MAINTENANCE OF EFFORT- A geriatric education center that receives an award under this subsection shall provide assurances to the Secretary that funds provided to the geriatric education center under this subsection will be used only to supplement, not to supplant, the amount of Federal, State, and local funds otherwise expended by the geriatric education center.CommentsClose CommentsPermalink

‘(9) AUTHORIZATION OF APPROPRIATIONS- In addition to any other funding available to carry out this section, there is authorized to be appropriated to carry out this subsection, $10,800,000 for the period of fiscal year 2011 through 2013.’.

Healthcare IT Stimulus and EHRs

The 20 billion dollar Health IT stimulus could potentially force doctors to choose "between VHS or Betamax at a time when we see Blue Ray on the horizon".
I fear that any large scale government spending on health care IT, especially in the area of EHRs (Electronic Health Records), will end up being corporate welfare for the large, established IT vendors. There are a lot of smart people developing the next generation of health care computing, but unfortunately they may be shutout from the market if this spending plan comes to fruition.

I've seen over the past several years how federal and state dollars have been wasted in creating RHIOs. Many of these RHIOs found that after the initial grant money dried up, there really wasn't a compelling business value that would lead to sustainability. The grant funds just made these entities chase some misguided business plan/vision which really did not address true needs in the community for which providers would be willing to pay for.

If EHRs are truly vital to the efficient and safe delivery of health care, and actually help physicians and other providers do their job well, then these end users should pay for the technology themselves. The argument made from the other side is that the cost of EHRs is more than physicians can afford. I think then, the real issue is, perhaps the current crop of EHRs is based on old, clunky, expensive technology. Unfortunately, we may not get to see the future technology for EHRs if the government dumps billions into forcing physicians to buy current systems.

Telemedicine in 1924?

The Concept of Telemedicine existed in 1924!
The only problem, the technology did not exist at that time. This magazine cover is quite remarkable in that it demonstrates the current concept of telemedicine, complete with videoconferencing, remote stethoscope and even an printer! Perhaps this young patient is receiving a prescription.
Also see this interesting article.

Bail out Money, how far does it go?

The folks at Powerline blog posted some interesting facts about the nearly trillion dollars in bail out funds:

A Dozen Fun Facts About the House Democrats' Massive Spending Bill

1. The House Democrats' bill will cost each and every household $6,700 additional debt, paid for by our children and grandchildren.

2. The total cost of this one piece of legislation is almost as much as the annual discretionary budget for the entire federal government.

3. President-elect Obama has said that his proposed stimulus legislation will create or save three million jobs. This means that this legislation will spend about $275,000 per job. The average household income in the U.S. is $50,000 a year.

4. The House Democrats' bill provides enough spending - $825 billion - to give every man, woman, and child in America $2,700.

5. $825 billion is enough to give every person living in poverty in the U.S. $22,000.

6. $825 billion is enough to give every person in Ohio $72,000.

7. Although the House Democrats' proposal has been billed as a transportation and infrastructure investment package, in actuality only $30 billion of the bill - or three percent - is for road and highway spending. A recent study from the Congressional Budget Office said that only 25 percent of infrastructure dollars can be spent in the first year, making the one year total less than $7 billion for infrastructure.

8. Much of the funding within the House Democrats' proposal will go to programs that already have large, unexpended balances. For example, the bill provides $1 billion for Community Development Block Grants (CDBG), which already have $16 billion on hand. And, this year, Congress has plans to rescind $9 billion in highway funding that the states have not yet used.

9. In 1993, the unemployment rate was virtually the same as the rate today (around seven percent). Yet, then-President Clinton's proposed stimulus legislation ONLY contained $16 billion in spending.

10. Here are just a few of the programs and projects that have been included in the House Democrats' proposal:

· $650 million for digital TV coupons.
· $6 billion for colleges/universities - many which have billion dollar endowments.
· $166 billion in direct aid to states - many of which have failed to budget wisely.
· $50 million in funding for the National Endowment of the Arts.
· $44 million for repairs to U.S. Department of Agriculture headquarters.
· $200 million for the National Mall, including grass planting.
· $400 million for "National Treasures."

11. Almost one-third of the so called tax relief in the House Democrats' bill is spending in disguise, meaning that true tax relief makes up only 24 percent of the total package - not the 40 percent that President-elect Obama had requested.

12. $825 billion is just the beginning - many Capitol Hill Democrats want to spend even more taxpayer dollars on their "stimulus" plan.

CMS Nursing Home Quality Measures

Here is a table of Nursing Home quality measure as defined by CMS.

Quality Measures	MDS Observation Time Frame *
Long Term Measures
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season	October 1 thru March 31
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	Looks back 5 years
Percent of Residents Whose Need for Help With Daily Activities Has Increased	Looks back 7 days
Percent of Residents Who Have Moderate to Severe Pain	Looks back 7 days
Percent of High-Risk Residents Who Have Pressure Sores	Looks back 7 days
Percent of Low-Risk Residents Who Have Pressure Sores	Looks back 7 days
Percent of Residents Who Were Physically Restrained	Looks back 7 days
Percent of Residents Who are More Depressed or Anxious	Looks back 30 days
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder	Looks back 14 days
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder	Looks back 14 days
Percent of Residents Who Spent Most of Their Time in Bed or in a Chair	Looks back 7 days
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse	Looks back 7 days
Percent of Residents with a Urinary Tract Infection	Looks back 30 days
Percent of Residents Who Lose Too Much Weight	Looks back 30 days
Short-Stay Measures
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season	October 1 thru March 31
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	Looks back 5 years
Percent of Short-Stay Residents With Delirium	Looks back 7 days
Percent of Short-Stay Residents Who Had Moderate to Severe Pain	Looks back 7 days
Percent of Short-Stay Residents With Pressure Sores	Looks back 7 days

Telemedicine Resource Part II

Writing a telemedicine business plan:
ATA Business & Finance SIG
- Business Plan Template document
- Business Plan Budget (xls)

Telemedicine Reimbursement

Getting Medicaid to cover more telemedicine services in your state

Not all states provide reimbursement for telemedicine services. Here is a document from the ATA, Medical Assistance and Telehealth - An Evolving Partnership that outlines steps that one can take in order to get reimbursement from the state Medicaid payers.

Interface Terminology for Medications: RxTerm

I came recently across RxTerms. It is meant to complement RxNorm.
It is described as being more focused on usability and efficiency as opposed to RxNorm, which is more of a reference terminology.

Potential applications are in prescription writing or medication history recording.

See the presentation here. Download the data files here.

"Ultrasound used to Enhance Chemotherapy" guest posting

Here is a Guest Posting by Sarah Scrafford, who writes regularly on the topic of
Online Ultrasound Technician Schools.


Ultrasound used to Enhance Chemotherapy

It’s the worst kind of curse to be afflicted by cancer – sometimes the only cure option available is chemotherapy which comes with its own side effects. The drugs that are used to kill the cancerous cells in your body end up damaging healthy tissue as well, causing adverse reactions like nausea, fatigue and pain. But there’s a way around this painful situation according to a study published in the Journal of the National Cancer Institute.

Scientists have discovered a new delivery method that makes it possible to target only the areas affected by the tumor by using special packets called nanobubbles to store drugs like doxorubicin that are used in chemotherapy treatments. When injected into mice, the bubbles traveled through their blood and accumulated in their tumors where they formed larger microbubbles. These areas, when exposed to an ultrasound scan, were open to imaging because of the echoes generated by the bubbles. The ultrasound also generated enough energy to burst the bubbles and release the drug directly onto the tumor.

The nanobubbles ended up serving two purposes – they helped image the tumor and also allowed the drug to be delivered only to the tumor-affected area thus preventing healthy tissue from being killed in the process.

Ultrasound is extremely popular as a diagnostic and imaging tool because it offers various advantages, the most significant of which is the fact that it uses no radiation to form images and so, is extremely safe even for children and unborn fetuses. But with the innovations that are being made in medicine day by day, new uses are being discovered for ultrasound, and the treatment of cancer is just one of them.

For patients who have been diagnosed with the dreaded disease and their families, this piece of news comes as a ray of hope – they can undergo chemotherapy without having to worry about or fear the horrible side effects of the drug. And for the rest of us, we can take heart in knowing that this is one more battle won in the war against disease that mankind is waging.

By-line:
This article is contributed by Sarah Scrafford, who regularly writes on the topic of
Online Ultrasound Technician Schools. She invites your questions, comments and
freelancing job inquiries at her email address: sarah.scrafford25@gmail.com