It’s Memorial Day, and a time to remember all who served our country.

There are millions who have done so over the years. A few have been singled out to receive a Congressional Medal of Honor because they stood out with some act of unbelievably unselfish heroism.

But there are so many who just did their duty, unknown and unnamed. They are honored fully as well, because each has served and each has contributed to our safety and freedom.

In healthcare, we are in the midst of a battle that in a way is even worse than one with tanks and guns, bombs and planes. The magnitude and confusion, the noise and the panic are the same. And, people are dying.

Just as in a war, each of us can make a difference. Some of us will become medal winners, some of us will not.

Sometimes instead of trying to analyze everything, it is better to examine an important slice. Our recent attendance and presentation at the New York Mid Atlantic Consortium, a collaborative of genetic programs, illustrated this clearly to us. During college and medical school we learned about Punnet Squares, polymorphism, and decreased penetrance. By 2011, genetics has exploded. We now have the human genome. Cancers can be analyzed and their own genome described. Personalized medicine is not only imminent, but it has started.

The problem is, however, that there are not enough people to do the work that is needed right now, needless to say, in the future. There is so much knowledge that no one person can know it all. These are big problems. These are problems, in part, because of funding. Those who are passionate about the field wonder where the funding can come from. Meanwhile, every other segment of society is asking the same questions. How can we do what we need to do without more funds? How come other interests get more funding? There is so much to do, so little time, so few personnel, and so little money. What can we do?

We at ClickCare have decided that each of us can make a difference. Maybe it won’t be a Congressional Medal of Honor difference, or maybe it will. But each of us, like each individual whom we remember this day, can make a difference. Each of us can push forward and improve our lot. Funding is important, but its value is negligible compared the richness of many who do their little part and collaborate with others. The rewards will come later, or doing your part better may be the reward in itself.

For our, part, I can put a stake in the ground and say: “If you don’t have the funds to buy a ClickCare subscription, call us and we’ll personally work with you to make it happen.”

ClickCare can bridge the gap between what can and should be and what is. We know that better collaboration brings better care, better access to that care, and better education of those who provide that care.

We applaud each of those we met at NYMAC and know that each of them are trying to make a difference. Many of them have, and many are still at it.

We at ClickCare will keep trying too because each of us deserves better, and each of us can make the world a better place.

There is a lot to talk about. Year end is for reflection. Year beginning is for looking forward. We are reticent to predict (as in Doctor, “how long does she have to live?”), but it seems as if all the buzz of stimulus monies, of EMRs, of personal health, of debate over health care, some fundamentals have been forgotten. Forget fundamentals, disregard principles, abandon commitments, but if you do so, you will be reminded that you “Can’t Fool Mother Nature”.

So we want to look forward to where ClickCare will fit in.

Three diverse concepts relate to each other: EMRs, Twitter with information overload, and the Cloud.

Many of us have made large, very large, investments in licensing, infrastructure and workflow for EMR/EHRs. We have spent a lot of human capital to be sure that we get on the wagon with meaningful use. We have kept a very close eye on stimulus money. Why would we want to challenge ourselves even more? Why, then, are we unsure of ourselves?. Perhaps, we feel that the fable of the Emperor’s New Clothes might come true. Perhaps, we can see no end in sight.

The Emperor's New Clothes

First, we should feel satisfied and confident that the EMR is already advancing. Electronic subscribing and fewer scattered repositories of patient information are most valuable. So while we worry that the “truth might come out”, all is not lost. The team at ClickCare is very committed to being sure that the EMR becomes an even more valuable resource because ClickCare and iClickCare can magnify it and fill the gaps that most fear to mention. There are limits to the EMR. Dr. Alok A. Khorana eloquently and wisely describes them in his brief essay, Physician as Typist, in the Journal of Clinical Oncology.

One point is the lack of focus on communication–his EMR author with him as the typist:

“I stare at the primary care physician’s note in front of me. I have been concerned about our mutual patient’s hypertension. I believe it has been exacerbated by the use of bevacizumab, and I have referred her back for additional management. All I need is an acknowledgment of the problem and a treatment plan. The note that I have received is three pages long and is filled with unrelated laboratory values, scan results, and jumbled-up text.”

In contrast were other notes, generated “by hand”:

I get other notes, too, from providers that haven’t yet adopted an EMR system. I made a recent referral for a patient with hematuria to a urologist. In a day or two, I received a one-page summary of the problem, including a differential diagnosis, the findings on cystoscopy, and the plan for additional surveillance. It was, really, all I needed. Another oncologic surgeon with whom I share patients always mentions the patient’s profession in the first sentence of the letter. It tells me something about the care that a surgeon who cares to find out such details will provide. However, as our institution transforms from a hybrid to a completely EMR system, these unique styles are likely to disappear.

What is the reason there is a difference between man and machine? Dr. Khorana perceptively notes:

“Recall that there are two major narratives associated with the physician-patient encounter. The first is the narrative told by the patient to the physician. The starting point of this narrative is relatively uniform: the complaint that brought the patient in. From here onward, however, the narrative can be remarkably free flowing and often tangential. To make sense of this free-flowing story, we as providers resort to a second narrative. The physician’s narrative repackages the patient’s tale, but in a format that serves the scientific goal of the note, which is to reach a diagnosis and treatment plan. Of necessity, it requires the act of listening closely and mindfully to the patient first.”

This article is clearly and cogently written. Reading it is highly recommended.

The reaction

What we would add is that ClickCare takes that very “act of listening closely and mindfully to the patient first”, and allows the listener to act upon it subsequently and cooperatively with other colleagues. Not with every patient, not with every visit, but when necessary and appropriate, to do so easily and quickly. Indeed, ClickCare offers the patient an audience of more than just one.

Another way of looking at this, is that there is too much information, and that communication is not taking place. Here are excerpts from an interview on the blog GIGAOM.

Om Malik, the blogger is interviewing Evan Williams, the cofounder of Twitter:

Om Malik: Ev, when you look at the web of today, say compared to the days of Blogger, what do you see? You feel there is just too much stuff on the web these days?,

Evan Williams:I totally agree. There’s too much stuff. It seems to me that almost all tools we rely on to manage information weren’t designed for a world of infinite info. They were designed as if you could consume whatever was out there that you were interested in.

Om Malik:Do you think that the future of the Internet will involve machines thinking on our behalf?

Evan WIlliams: Yes, they’ll have to. But it’s a combination of machines and the crowd. Data collected from the crowd that is analyzed by machines. For us, at least, that’s the future. Facebook is already like that. YouTube is like that. Anything that has a lot of information has to be like that. People are obsessed with social but it’s not really “social.” It’s making better decisions because of decisions of other people. It’s algorithms based on other people to help direct your attention another way.

They also discuss immediacy and relevancy.

Om If you were starting Twitter today – same service, but in a world that is very mobile, very multi-touch driven and a very portable web – what would it look like?

Ev: I’d have to think about that for a while but i don’t think it looks that different than what we have today. Twitter is a natural fit for mobile – it has the immediacy. There is nothing significantly missing, but (we) need to really boost relevancy. If you can’t read everything, then (what is that) you really do need to know right now.

Immediacy creates a need for mobility. Mobility creates a need for immediacy. Again, ClickCare supports and enables the EMR by enabling both immediacy and mobility regardless of which EMR was purchased.

Which brings us to the Cloud, and our last prediction about where ClickCare fits in. Many will become comfortable with the Cloud, immediacy and access. There are some who already expect it. The last mile of internet access not with standing (ClickCare can use 3G and Edge), communication with pictures and words can be the norm. We will expand more on this in another post.

In the meantime our prediction is that the patients will begin to get better care this year. We just need to look ahead and beyond.

A lot of people seem to think so.  The most recent report, abstracted by research2guidance entitled “Global Mobile Health Market Report 2010-2015” was reported at mHealth Summit last week.  We also heard the same theme when we presented at mHealth in San Diego, last month.

The statistics are amazing, and all point to the same message:  we are all mobile creatures and would rather not be on a leash.  Research2guidance estimates that 500 million people will be using smartphones in various ways for health care.  These range from continuing medical education to unique monitoring devices.

We at ClickCare would caution, however, that the right tool, at the right time, at the right price should be used.  We could not be more enthusiastic about iClickCare and the iPhone, we also know that sitting quietly at a large, easy to read computer screen can be as valuable as taking and sending a secure message and photo/video with the iPhone.  That is why we have both available and included with each subscription.

Similarly, one can subscribe either via download from the App Store, or from our website ClickCare.com .  A free two week trial lets you start collaborating with your colleagues immediately–with an iPhone, with a desktop, with a laptop or iPad.

Use a needle to sew a laceration or a shirt.  Use a sledgehammer to crush a rock.

Use your ClickCare subscription in the way that is best for you at a particular time and in a particular place.

We look forward to your comments.

Rite Aid to pay $1M to settle HIPAA privacy case

The regulators mean business. This is not the first enforcement of HIPAA by any means, but it is a significant one both in scope and in penalty.

We often hear busy doctors say I just use email. The patient says it is OK.

It may be OK with the patient, but it is not OK with regulators. In this case, both the Federal Trade Commission and the Office of Civil Rights of Health and Human Services have accused Rite Aid of improperly disposing of records in an unauthorized trash container.

Occasionally, it seems best to have the end justify the means – it more likely will not be the right thing to do. In matters such as HIPAA, it is a high risk maneuver. Since ClickCare can get to the same end in a legal way, why not use it? Further, all collaborations are saved and available for reference and teaching.

The HITECH act (which provides loans for EMR adoption) added teeth to the HIPAA regulations:

The Health Information Technology for Economic and Clinical Health (HITECH) Act provides a tiered system for assessing the level of each HIPAA privacy violation and, therefore, its penalty:
Tier A is for violations in which the offender didn’t realize he or she violated the Act and would have handled the matter differently if he or she had. This results in a $100 fine for each violation, and the total imposed for such violations cannot exceed $25,000 for the calendar year.
Tier B is for violations due to reasonable cause, but not “willful neglect.” The result is a $1,000 fine for each violation, and the fines cannot exceed $100,000 for the calendar year.
Tier C is for violations due to willful neglect that the organization ultimately corrected. The result is a $10,000 fine for each violation, and the fines cannot exceed $250,000 for the calendar year.
Tier D is for violations of willful neglect that the organization did not correct. The result is a $50,000 fine for each violation, and the fines cannot exceed $1,500,000 for the calendar year.
The HITECH Act also allows states’ attorneys general to levy fines and seek attorneys fees from covered entities on behalf of victims. Courts now have the ability to award costs, which they were previously unable to do.

Collaborate legally.

Comments based on http://www.healthcarefinancenews.com/news/rite-aid-pay-1m-settle-hipaa-privacy-case,  quoting Editor’s note: This is an excerpt from the April 2009 edition of the HCPro, Inc. newsletter, Briefings on HIPAA.

As a surgeon, I dread complications.

I think through anything that I could do to avoid them. I worry about alternatives but despite worry and action, they occasionally happen. Not often, but enough to make me worry as I sleep, drive around, and anticipate what needs to be done. And it’s not only me. Fear and dread have driven many of my closest colleagues to retire early.

I have been told to never take on difficult cases: “Don’t try to save the world, Larry.”  My malpractice carrier would prefer I side-step those who are as infirmed with high expectation as they are with cancer. And, as a thoughtful recent article in the New York Times points out, there is the financial and moral question of who pays for the complications once they arise.

So, what does this have to do with ClickCare?  A lot.  While we can try to control infection with a thorough preoperative prep and prophylactic antibiotics. We can share our concerns and have our patients share the risk since most of the time it is indeed, the patient’s complication anyway.  (Not always though, as there are plenty of bad backs, burning necks, AIDS and hepatitis among the practitioners).

We can also make sure that things do not fall through the cracks.  We can be sure that the best minds of our trusted colleagues are made available to the patient.  We can use ClickCare.  Just as we can get complications ourselves from our patients, we can get satisfaction and reinforcement of knowing that we know that we did the right thing, that we tried our best, that we left no stone unturned.  That we truly collaborated on behalf of the patient.

The seeming short-sightedness of the Centers for Medicare and Medicaid Services not wanting to pay for complications (while they also refuse to pay for the tools that would prevent them, such as telemedicine) makes you wonder. While finance catches up with technology, I guess we just have to do the right thing.

For us, the right thing has been to keep taking the hard cases, constantly being vigilant, and taking every opportunity to be leaders in the field of collaboration and proactive care.

Harrison Ford isn’t one for small talk. And he hadn’t ever spoken in public about Star Wars… until last week.

In commemoration of the 30th anniversary of Star Wars, and to raise money for St. Jude’s Children’s Hopsital, Harrison Ford finally discussed the making of Star Wars.

One comment from Mr. Ford caught our imagination because of its connection to our methods of making ClickCare itself (equal measures collaboration, creativity, medical expertise, and art)… and to the process of making the “product” of fantastic medical care for our patients:

“[Making movies] is a collaborative process. And I think what it speaks to more than anything else is that when you have the opportunity to make something and you care about what it is you’re making, you try and you try and you try. You just don’t settle. You try because you care about the product.”

Here at ClickCare, we draw from wisdom in many fields, especially where we can learn something about collaboration. As you know, we are impassioned about collaboration in medicine.  This is inspiring, even if it is Hollywood.  Collaboration and creativity go together–in medicine, and in movies.

One of the joys of running ClickCareis being close to our customers’ hopes and fears. Sometimes we hear comments that inspire and invigorate. Other times, conversations are about:

“It would be nice, but…”
“I would like that, but there’s no budget for…”
“It is important, but I don’t know how I would implement it.”

They are words we might say about following a dream, or taking vacation, or sending a kid to college.  I hear the same words when I ask patients to stop smoking, lose weight, or exercise.

We know that budgets are cut, health care bills come and go, technology muddles, and there are always 101 items on the to-do list. Be that as it may, my take is this: We need to think bigger. Run around more. Dream big dreams, do big things. Take control back.

Benjamin Franklin sat in the hall during the Constitutional Convention for many days and there was one chair that caught his eye. The chair had a vibrant painting of a sun just above the horizon and Mr. Franklin kept staring at it. Finally, as the Declaration was signed, Franklin spoke. He said he had stared at that painting wondering about the half-sun and whether it was rising or setting. He concluded confidently: “Now at length I have the happiness to know that it is a rising and not a setting sun.”

Here at ClickCare, we too are confident the sun is rising. We are confident it’s rising because there is evidence for it. We are confident it’s rising because our experience tells us so. Mostly, we are confident it’s rising because that is the only useful way to move forward.

Join us.

We are now on at least the 60th version of one of the screens of the new software!  New technology gives us opportunity to make things clean, simple and easy.  It is a lot of work… and it is sending us to the book shelf.

We have been enjoying Paul Glen’s Leading Geeks: How to Manage and Lead the People Who Deliver Technology, which, for all of us who are intimately and constantly involved, is not so much about managing geeks, but about managing ourselves (there are a bunch of us).

While we’re not necessarily admitting to being geeks, this quote from one of our team members could be a clue:

I just put a zip on the FTP called “nathan_mockups_320x480.zip” — these are our latest iPhone mockups with the iPhone device part removed (they’re just the 320×480 part that shows on the screen itself).  I recommend that you sync these as photos to your phone and try them out under the Photos app.  I can explain how if necessary. They overall look pretty good but one of things you’ll notice is the fonts in the rows on the home_list view did get kind of small.

For the ultimate example of geeks (not that we are…) and their friends and comments… a little geekified viewing on Bill Gates and Steve Jobs, who were even said to go on double-dates together, back in the day. Geeks are people too, you know.

The recent open letter by Steve Jobs, CEO of Apple, is worth a look.

The details are largely unimportant.  Technical jargon aside, it is a discussion about the best way to create and distribute ideas with video over the web. Most important? While it appears to be about technology, it is really about relationships.

As medical professionals, we have traditionally had a single relationship, that of our patient. Although the “businessization” of medicine has created more relationships, our relationships still tend to be long-term. These relationships, whether with other providers, with patients, with hospital staff or community members, are built over years and are the foundation of our art and science.

It is hard for us as medical professionals to relate to shifting or short-term relationships. So as Mr. Jobs describes an ideologic confrontation with Adobe, it seems unfathomable that past relationships, including a 20%  ownership, seem to have gone for naught.

It’s fascinating to us at ClickCare, because we try to help our customers (some of the most important long-term relationships we have) by choosing the best ways of presenting and sharing information. As we finish up “version 3? of ClickCare, we are constantly making key technical decisions… and we make these in the service of (never at the cost of) our long-term relationships with our customers. We are doing our best and we also look forward to hearing from you.

In the chaotic aftermath of the earthquake in Haiti, Daniel Woolley needed help. Stuck in rubble, alone, help didn’t come for hours, and then days. Soon, Daniel realized he had a resource that would save his life. In these critical hours, he used information from his iPhone to treat his injuries and ultimately survive the earthquake.

Was there any way for the creators of the technology that supported this miracle to have predicted it? Probably not. But just as “the exception proves the rule,” it is the unintended uses of technology that really showcase its power. Human ingenuity makes magic out of plastic and circuit boards.

That’s the up-side. The down-side? Human foibles can also make technology create unintended outcomes that are undesirable. As technology improves, people innovate uses for it that outstrip the regulatory and social structures that governed “life before” the technology. It happens in every field- business, government, your daughter’s social life… but nowhere is the discussion more vital than in the medical field.

Answers are coming from multiple sources. Scientific American notes that the FDA is now considering multiple forms of oversight. New broadband policy posits a collaboration between the FDA and FCC.  It’s where science meets politics… and the intent is to protect us.

Over the past 15 years, as physicians using technology to collaborate, teach, and improve access to care, we have also wrestled with these challenges. Our answer? Self-regulation at its best.

We developed a design principle that is HIPPAA-compliant and just plain effective: the “requesting provider” (the one asking for the consult) is the final protector (she maintains full responsibility at all times) of the patient. This provider uses the consult as one piece of input, always analyzing, prioritizing, and assessing risk.

We work with providers, when they join us in ClickCare, to be cognizant of this, and realize that they must think as well as react.  ClickCare makes all of this much easier, and lets you do your job better, but it is you who is helping the patient, and you who must decide. It’s you who creates the magic… as the government works to catch up to you.