Free Cloud-Based EMRs

I ran across this post by Paul Levy the other day:

"By the way, speaking of electronic medical records and meaningful use, we cannot fail to mention the upstart company Practice Fusion.  Focusing mainly on independent physician practices, Practice Fusion CEO's says, "We’re effectively the Salesforce for doctors, and the Facebook for health.”  Doctors can sign up for free for an EMR that will meet the meaningful use criteria, making them eligible for the $44,000 in federal incentive payments.  The service offers labs, e-prescribing, scheduling, charting, and billing.  The revenue model is based on advertising by labs, pharmacies, and drug companies who want to be seen by these medical decisions-makers.  The company promises that the basic EMR services will always be free, but I suspect that future revenue may also come from enhanced services."

http://runningahospital.blogspot.com/2012/06/this-is-not-cold-fusion.html

What a thought that we now have fully functional and integrated EMRs hosted entirely in the cloud that are free for the end users (docs and clinics).  Since it's cloud based, you also don't need to have servers to host data and don't need to worry about updates to a proprietary piece of software.  

I wonder what a product like this will do for the free clinics and other small primary care practices in our country that previously may have been resistant to adopting electronic record systems because of prohibitive up front costs (of both time and money)!

Unintended Consequences / Vaccination Struggles

So it appears vaccination coverage isn't just a developed country problem and docs across the world are dealing with some of the exact same problems:  rumors swaying public opinion.

Whether is is the (completely discredited) connection between MMR vaccines and Autism or now the connection that Pakistanis are making between polio vaccination campaigns and foreign spies, these stories are hurting those kids who are getting ill with preventable diseases.

Take a look at this CNN article for the whole story (video included).  In a nutshell, the local media highly published a story that the US was (in part) able to gain access to the Bin Laden compound through a fake vaccination scheme and this has since engendered massive distrust of vaccination initiatives.  Perhaps the greatest tragedy in this case is Pakistan is one of several countries where polio is still endemic, so failed vaccination campaigns mean kids will grow up paralyzed.  Pretty heavy consequences indeed.

April Newsletter

The April edition of our quarterly newsletter, Publicly Speaking, is out with some great ideas about how you can get involved internationally. If you would like any additional information from any of the authors let us know and we'll happily connect you! 


Have a great week! 
CGPH - Publicly Speaking (April 2012 Newsletter)

Public Health Education Resource

If you've been looking for a public health education resource the information below is a great place to start. Should you have any questions we'd happily put you in contact with the creators. Feel free to e-mail me at lauren.page.black@gmail.com should you wish to speak with them.

Have a great week!
Lauren-Page
AMA Committee on Global and Public Health 

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In response to an informal needs assessment administered by the Regional Medicine-Public Health Education Centers Initiative (an effort to better integrate public health content and skills into medical education supported by AAMC’s cooperative agreement with the Centers for Disease Control and Prevention), and the AAMC’s Organization of Student Representatives (OSR), we have developed a modular power point presentation that we hope will be a helpful resource for students and faculty at your institution.

These slides were developed for medical students and faculty. They provide an overview of the relationship between medicine and public health, review why public health is relevant to medical education and careers, and include recommendations and resources to improve public health content in medical education.

Users may select slides and incorporate them into their curricula, presentations, and other efforts to advocate for improving public health perspectives at their institutions.

The slides are divided into seven sections to facilitate their use:

•What is public health? What is the relationship between medicine and public health?

•What determines health?

•How is public health important to your training and careers?

•What do we know about student perspectives on public health in medical education?

•Enhancing public health in your curriculum and training

•Specializing in Public Health and Preventive Medicine

•Resources

•CDC Professional Student Programs and the Epidemic Intelligence Service

The slide-set can be accessed online at www.aamc.org/rmphec at the bottom of the right-hand column under Student Resources.

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There’s more to food culture than just restaurants

Actor Wendell Pierce, best known for his roles on HBO’s “The Wire” and “Treme,” is now a proud business owner in his hometown of New Orleans. After opening a convenience store this winter, he and a local business partner plan to open a string of grocery stores beginning this summer. His aim is two-fold: to encourage economic growth in New Orleans and to bring nutritious and affordable food to a food desert.

The lack of grocery stores in New Orleans is a problem made more prominent post-Katrina. The majority of the 21 supermarkets that do exist today are not close to the areas hardest hit. A 2007 survey from Tulane showed that although 58% of low-income residents do not have access to a car, 60% must travel a considerable distance (3 miles) to reach a grocery store.

At first, Pierce intended to come back to New Orleans and just build houses but soon recognized that convenient access to healthy food was necessary for the successful revitalization of the neighborhood. “You start to realize all the parts of infrastructure that are needed,” he comments on his newfound awareness of the complex inter-connectedness of basic necessities.

With the opening of Sterling Farms, his new full-service grocery store, Pierce hopes to revive the sense of community surrounding food that he says characterized much of his childhood. In addition to all the expected services of a grocery store, Sterling Farms will address the specific needs of this community by providing a free shuttle for shoppers and a monthly cookout to raise community funds. Since losing a bid to launch the stores in his own neighborhood of Pontchartrain Park, Pierce has looked elsewhere. Sterling Farms will be located across the Mississippi in Marrero, LA, a neighborhood in which a quarter of households earn less than $25,000 a year. In lieu of a fixed rent, he will pay 2% of sales that exceed $9 million yearly.

Pierce acknowledges the parallels between the lessons he is learning and his personal frustrations with systemic malfunction and those depicted in “The Wire” and “Treme.” “It’s life imitating art, and art imitating life,” Mr. Pierce said.

Check out the full New York Times article at: http://www.nytimes.com/2012/03/07/dining/wendell-pierce-to-open-a-grocery-store-in-new-orleans.html?hp

The Birth of a Movement

My love for Lady Gaga is no secret, but since the launch of her new “Born This Way Foundation,” I have even more reason to sing her praises. Last month, Lady Gaga shared the stage of Sanders Theatre at Harvard with Oprah Winfrey to launch what she calls a movement to “challenge meanness and cruelty by inspiring young people.” It is more than an anti-bullying campaign but a youth empowerment campaign that aims to change an entire culture.

The three pillars of her campaign are safety, skills, and opportunity. She aims to create a culture in which every person feels safe, has the skills to stand up for one another, and uses the opportunities that arise to spread the message of tolerance.

Probably my favorite moment from the launch event was when Alyssa, a very brave young person who was a member of the opening panel, was asked to explain what she does at school. She said, “I try to set an example...then the rest will follow.” Telling stories of success will be an important part of what the foundation does.

There has been a lot of attention paid recently to cyber-bullying because of its visibility, but statistics show that the most common type of bullying is still face-to-face. Incidentally, the foundation is partnering with Blue State Digital to use social media to spread the message of love and acceptance.

I applaud Lady Gaga’s efforts to reach out to experts, disseminate information, and begin interdisciplinary dialogues. Her partners include the MacArthur Foundation and the Berkman Center for Internet and Society at Harvard. Secretary of Health and Human Services Kathleen Sebelius, Deepak Chopra, and psychologist Susan Swearer all participated in her launch event.

This foundation intends to improve the health and well being of young people from the bottom up. Lady Gaga understands this will take time. Tell a friend and spread the message!

Watch the launch of the Born This Way Foundation and read some notes from “The Kinder and Braver World Project” from the Berkman Center.

The International Medical Brain Drain – Are we to blame?

I read an interesting New York Times article today addressing the shortage of doctors in the developing world. There are some disturbing statistics:

- In the US, there is 1 doctor for every 416 people vs. 1 for every 23,000 in Zambia

- The median salary of a surgeon in New Jersey is $216,000 in New Jersey vs. $24,000 in Zambia

- One in 4 doctors in the US is trained overseas

Is America to blame for the shortage of doctors in sub-Saharan Africa? There is a great demand in the US for doctors, especially primary care physicians: statistics project a shortage of 200,000 doctors in this country in 10 years. With high salaries, innovative technology, and enticing immigration laws, the US attracts more foreign doctors every year than Britain, Canada, and Australia combined. Some states have legislation that allows foreign doctors to stay in the US after residency if they would practice in underserved or rural communities here. So far, more than 8,500 doctors have done so. But what is a gain to one country is a loss to another.

A 2008 article in the Lancet suggested that that the active recruitment of medical professionals from Africa be viewed as a human rights violation. It described recruitment agencies that woo medical workers through advertisements, workshops, e-mails, and even text-messages.

But for some doctors, it is the plain reality of practicing in their homeland that causes them to leave. Dr. Kunj Desai, from Zambia, now a resident in surgery in New Jersey, described repeated instances of senseless death due to lack of resources. “We were just pretending to be doctors,” he said of his time at University Teaching Hospital in Lusaka, Zambia.

There is some international funding for training and retention of local doctors but Western aid agencies often hire local talent to do research, not see patients, contributing to an “internal brain drain.”

The solution probably involves a combination of more high-quality training programs and hospital resources, higher salaries, and better working conditions for foreign physicians in the developing world. What the US can do instead of recruit foreign physicians is to contribute to the existing infrastructure for the delivery of medical care in other countries. On the issue of teaching, I am particularly interested in exchange programs for residents, which allow both parties valuable training experiences.

Check out the full article at:

http://www.nytimes.com/2012/03/11/magazine/america-is-stealing-foreign-doctors.html

Public Health in a Military Setting

For anyone interested in the military system of delivering medical care and offering public health interventions, here is a link to a perspective piece in the NEJM this week:

http://www.nejm.org/doi/full/10.1056/NEJMp1112981?query=health-policy-and-reform


It deals with issues of protecting the health and welfare of our soldiers while they are deployed.  In fact, throughout history, many more casualties in war stem from disease and other public health concerns and do not come directly from combat itself.  We're doing better these days, but a lot of the success hinges on whether or not soldiers are compliant with the interventions recommended.  For example, as a consequence of not adhering with anti-malarial prophylaxis, a large section of a unit of marines needed to be evacuated to the states for treatment of ... malaria.

Take a moment and check out the article!

Give and You Shall Receive: A Call for Organ Donors

Successful attempts to increase the number of organ donors have been elusive, confounded by ethical and religious questions and ambiguities. In the US, we have the opt-in system: people can register at any time to be organ donors, but nearly 18 people die every day waiting on the transplant list. Spain and Austria have the opt-out system: people are presumed organ-donors unless they (or family) say otherwise, but the number of donations doesn’t necessarily differ. Is it time to try a new system? If you are willing to donate your own organs, should you get priority to receive an organ? A new law, to take effect in Israel in April, will do just that.

Patients who have organ donor cards or whose family members have donated an organ in the past will get priority for transplant over other patients who are at the same level of medical severity. The law will provide for adequate compensation for the donor, including 40 days of lost wages and medical expenses paid.

The hope is that this law will encourage more people to register as organ donors, and so far it has been effective. After a massive 10-week advertising campaign targeting shopping malls, billboards, and newspapers, 70,000 people registered as donors.

The law was created in careful coordination with rabbis and religious leaders, which should make it appealing to most Israelis. What complicates matters is the orthodox interpretation of brain death and the Haredi rule against organ donation. This puts an entire group at a disadvantage under this new system.

Are systems that grant non-medical priority to some people on the transplant list inherently unjust? Perhaps. But I believe that the real injustice lies in systems where wealth buys an advantage and the poor are taken advantage of. What I like about this new practice is that it paradoxically equalizes the playing field – money can’t buy you priority on the transplant list but altruism can, and we all have the capability for that.

As a fourth year medical student, I did a transplant surgery rotation that taught me that the decisions we make about our organs after death often have effects greater than we had imagined. I will never forget what a new liver meant for my patient, a 35-year-old mother of two. She had become less alert and aware over the course of two weeks, dipping into the phases of inexplicable hemolytic crisis and encephalopathy that characterize hepatic decompensation. We got the call about a donor on a Friday afternoon and by nighttime had successfully transplanted the liver in my patient. The next morning, I went to visit her in the ICU. She greeted me with the first coherent salutation I had heard from her in a long time.

I never knew the name of the donor, just that she was in her 50s, in good health, and brain-dead. What I do know is that her decision to be an organ donor turned a tragedy into an opportunity for new life for a perfect stranger. She would deserve the same.

Check out Dr. Ofri’s post on the NYT Well Blog:

http://well.blogs.nytimes.com/2012/02/16/in-israel-a-new-approach-to-organ-donation/

Romance, Revenge, and....Responsibility?

This can change people’s attitudes and behaviors. It has even been described as “a real catalyst for social change.” Nope, we’re not talking about politics or literature. We’re talking about soap operas. Yes, that cataclysmic romance between Felipe and Elena may actually be teaching you a thing or two about public health. With a viewership in the millions and characters that people can relate to, soap operas are an excellent medium for delivering education and social messages.

According to an article in the New York Times, the first soap opera that intentionally attempted education was a 1969 Peruvian telenovela called “Simplemente Maria,” in which a country girl moves to the city and learns to read and sew. After Maria marries her literacy teacher, enrollment in literacy classes in Peru skyrocketed. A similar pro-literacy telenovela in Mexico called “Ven Conmigo” had comparable effects.

But can soap operas influence behaviors such as safe sex and family planning? That seems to be the case. Regular viewers of “Soul City” in South Africa are significantly more likely to use condoms during sex, and soap opera viewers in Brazil have lower fertility rates than their counterparts.

The creators of socially conscious soap operas understand the importance of collaborating with local organizations to provide helplines and social services, and can even receive funding from the government or international donors (such as USAID) for their work.

Read the article (and watch a clip from Kenya’s “Makutanu Junction”) at:

http://opinionator.blogs.nytimes.com/2012/01/26/steamy-plots-with-a-social-message/

Public Health Headlines

A couple of public health headlines taken from the AMA Morning Rounds this week:

US obesity rates may be leveling off.

New data indicating that US obesity rates have stabilized generated extensive news coverage, including segments on two national television networks, with many sources contrasting the high prevalence of obesity with the fact that rates are not climbing. NBC Nightly News (1/17, story 6, 2:45, Williams) reported, "in new numbers just out, the CDC finds about one in three American adults and one in six kids and teenagers in this country are heavy enough to be considered obese." The CBS Evening News (1/17, story 8, 0:20, Pelley) reported that "these are about the same levels as in 2003."
The AP (1/18) reports that two "CDC reports summarize results of national health surveys in children and adults, which are conducted every two years." According to the AP, "The 2009-2010 reports involved nearly 6,000 adults and about 4,000 children, from infancy through age 19." The findings, divided into two reports (one on adults and one onchildren and adolescents ) "were released online in the Journal of the American Medical Association."
USA Today (1/18, Hellmich) reports in "Your Life" that, according to the data, "The average body mass index (BMI) of men rose to 28.7 in 2010 up from 27.7 in 2000," while "the average BMI" of women "remained unchanged at about 28.5."

Only 25% of kids use sunscreen regularly.

The Los Angeles Times (1/24, Roan) "Booster Shots" blog reports that "kids are really bad about using sunscreen consistently," according to a study published Jan. 23 online in Pediatrics. "Researchers studied fifth-grade children in Massachusetts in 2004 and then re-surveyed the same 360 children three years later. In the first survey, more than half of the kids said they had experienced at least one sunburn, and this rate did not change three years later."
"Despite numerous efforts to encourage people to wear sunscreen, a new study shows only 1 in 4 children regularly uses sunscreen," WebMD (1/24, Warner) reports. "The results showed that half of the children reported routinely wearing sunscreen in 2004, but only 25% did so in 2007." The article adds, "Researchers say the results show that the time between ages 11 and 14 is a critical time in developing attitudes about tanning and wearing sunscreen, especially among girls."
ABC News (1/24, Carollo) points out, "Most of the study participants said they liked the appearance of a tan, and the number of children who said they spent time in the sun to get a tan increased over the three-year period." Lead author Stephen Dusza, said, "At the same time, there was a signficant reduction in reported sunscreen use." Notably, "Dusza and dermatologists not involved in the research said the findings highlight the importance of finding effective ways to educate children of this impressionable age group about sun safety and the potential dangers of excessive exposure to ultraviolet light."

Let's pay more attention...

Once again, saw an interesting public health headline in the AMA Morning Rounds email this morning.

"Report notes increase in accidents of people wearing headphones while walking"

A slightly closer read sheds a little more light on what they're looking at.  This was a retrospective study of accidents over a 7 year period.  The accidents mentioned weren't simply stepping wrong off a side-walk or walking into a light-post.... we're dealing with people getting hit and killed by trains and the like!

In something along the lines of 30% of the cases, a warning sound was present before the victim was hit, but they did not respond (presumably because the music / sound from the headphones drowned out the warning sound).

This sure says a lot for a simpler and more attentive approach to life -- perhaps we don't always need to be plugged into our electronics (especially when around trains and fast moving cars).

For more info:  The ABC World News spot (16:42 into full broadcast from 1/16), an article in HealthDay , the study itself, and another article in MedPage Today.

Joint Commission Sentinel Event Alert -- Sleepiness

The Joint Commission published a short article last month on sleep deprivation and it's effects on patient (and provider) safety.  There are a lot of issues at play here and changing the culture of how we learn and practice medicine isn't quite as simple as saying, "Let's work fewer hours."  Though to guide our discussions, it is useful to understand what has been presented in the literature.

A selection (quoting from the Joint Commission article -- full sources can be found in the article) from a 2007 article in the Joint Commission Journal on Quality and Patient Safety:

"The article reports that residents who work traditional schedules with recurrent 24-hour shifts:

- make 36% more serious preventable adverse events than individuals who work no more than 16 consecutive hours
- make 5 times as many serious diagnostic errors
- have twice as many on-the-job attentional failures at night
- experience 61 % more needlestick and other sharp injuries after their 20th consecutive hour of work
- experience a 1.5 to 2 standard deviation deterioration in performance relative to baseline rested performance on both clinical and non-clinical tasks
- report making 300% more fatigue related preventable adverse events that led to a patient’s death"

Lockley SW, et al: Effects of health care provider work hours and sleep deprivation on safety and performance. The Joint Commission Journal on Quality and Patient Safety, November 2007;33(11)7-18, http://www.jointcommission.org/JQPS_11_07/

The 90%

While vacationing in New York last week, I visited an incredible exhibit at the United Nations visitor’s lobby showcasing innovative solutions to problems facing the world’s urban poor: safety, clean water, the spread of disease, and transportation.

The exhibit, called “Design With the Other 90 Percent: Cities,” focuses on the nearly one billion people (the 90%) living in informal settlements throughout the world. The recurrent themes of the exhibit were incremental design, the use of cheap and local materials for construction, and efficient use of waste.

The concept of incremental design was applied to everything from bicycles to buildings. There was a bicycle that could be re-assembled to make a cart. In Chile, architects designed basic houses (including bathrooms and kitchens) that could then be modified and tailored to the needs of future residents by those residents.

In Paraguay, loofah panels were used to build walls and elsewhere, sandbags were utilized for insulation.

There is a “biolatrine” in Kenya that converts human waste to fertilizer and gas for cooking and heating, a communal oven, also in Kenya, that uses trash as fuel, and various systems for recycling and water purification.

On the medicine front, there are public health campaigns waged through text message, HIV self-testing kits with instructions in both pictures and words, and “medikits” that include low-cost medical devices made from locally available inexpensive parts.

Some of the coolest work in my opinion is the drawing of informal settlement maps that identify locations for water and sanitation in addition to schools and clinics. These maps function both as a medium for sharing information between residents and a way to identify priorities for change in the community. It goes to show that data collection is an important first step in community improvement projects.

These projects were collaborations between NGOs, architects, engineers, community members, and sometimes local governments too.

Overall, it was a thoughtful and creative portrayal of ideas for sustainable change. The exhibit ends on January 9^th. Check it out if you’re in the area!