Feature Articles

How are Clinical Decision Support Artifacts Tested Today?

In October 2018 the Centers for Disease Control and Prevention (CDC) issued a Request for Information (RFI) for a Natural Test Collaborative (NTC). Through a series of questions, the RFI seeks opinions and information about "The development of a national testbed (notionally called the National Test Collaborative (NTC)) for real-world testing of health information technology (IT)" and "Approaches for creating a sustainable infrastructure" to achieve it. The scope of this RFI is daunting. It might be useful, rather than to try to tackle this whole topic broadly but superficially, to take just one Clinical Decision Support (CDS) domain and show as completely as possible how testing is currently done.

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The Empire Strikes Back

It seems deeply ironic that a week after I wrote about how even giant companies eventually get surpassed, I'm writing about the resurgence of one such giant, Microsoft. Last week Microsoft won back the title of world's most valuable company (as measured by market cap), passing Apple. Apple had that distinction since 2012; Microsoft hasn't had it since 2002. Admittedly, Microsoft was only able to pass Apple because a recent tech stock downturn dropped Apple from its record trillion-dollar valuation, and, as of this writing, Apple has pulled back in front again, but the fact that it is a race again says a lot about Microsoft.

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CDC Issues RFI for Real-world Testing of Health Information Technology

In October the Centers for Disease Control and Prevention (CDC) issued a Request for Information (RFI) for a Natural Test Collaborative (NTC). Through a series of questions, the RFI seeks opinions and information about "The development of a national testbed (notionally called the National Test Collaborative (NTC)) for real-world testing of health information technology (IT)" and "Approaches for creating a sustainable infrastructure" to achieve it. The scope of the questions is somewhat confusing and quite broad, starting with Clinical Decision Support (CDS) and electronic Clinical Quality Measures (eCQMs) but quickly expanding to Electronic Health Records (EHR) and interoperability (not precisely defined).

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The Big Get Bigger, Until They Don't

You may have missed it, but the Open Markets Institute released a report on what it calls "America's Concentration Crisis." The report begins bluntly: "Monopoly power is all around us: as consumers, business owners, employees, entrepreneurs, and citizens." As David Leonhardt wrote in his op-ed about the report, "The federal government, under presidents of both parties, has largely surrendered to monopoly power." Their associated data set details market concentration within 32 industries, several of which are health related. For example, in electronic health record systems, the top 3 firms account for 58% of the market, whereas in pharmacies/drugstores, the top 3 control 67% (and the top 2 alone have 61% share).

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Is the US Finally Ready to Get Serious About Biodefense?

Biological and other disaster threats - whether accidental, driven by forces of nature, or intentional - pose fairly grave risks to the United States and the world. Situational awareness has been a conspicuous topic ever since the 9/11 attacks and the anthrax scare that followed shortly thereafter. Since then we have experienced numerous disasters: health impacts of major weather events such as hurricanes and earthquakes, new virus outbreaks like Ebola in Africa, raging wildfires on the West Coast (I live in California), and the ever-present threat of pandemic flu which a hundred ago infected some 500 million people across the globe and killed an estimated 50 million people worldwide, according to the Center for Disease Control and Preparedness (CDC). But since the initial flurry of public health preparedness funds in the ensuing several years after the 9/11 attacks, this topic has not had a high priority at CDC nor the funding necessary to implement it successfully.

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The Business of Healthcare Is Business

Hmm, that headline doesn't seem right, does it? I mean, shouldn't the business of healthcare be, well, health? Or, at least, caring? Actually, shouldn't the business of healthcare be patients? After all, everyone in healthcare says it's all about patients. Everyone says they're patient-centered, whatever that means. But think about this: who in healthcare gets paid for you to be healthy? Or, conversely, who in healthcare doesn't get paid when you get sick, or when you don't improve under their care? Whether we planned it or not, whether we admit it or not, or whether we like it or not, our healthcare system is a business that has become about making money.

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How Open Source Hardware Increases Cybersecurity

Hardware hacks are particularly scary because they trump any software security safeguards-for example, they can render all accounts on a server password-less. Fortunately, we can benefit from what the software industry has learned from decades of fighting prolific software hackers: Using open source techniques can, perhaps counterintuitively, make a system more secure. Open source hardware and distributed manufacturing can provide protection from future attacks...security is one of the core benefits of open source. While open source is not inherently more secure, it allows you to verify security yourself (or pay someone more qualified to do so). With closed source programs, you must trust, without verification, that a program works properly.

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Open Source Goes Corporate: Can Open Healthcare Be Far Behind?

If you aren't in IT, you may have missed the news that IBM is acquiring Red Hat, a leader in the open source Linux movement, or that, a couple days prior, Microsoft closed on its acquisition of GitHub, a leader in open source software development. Earlier this year Salesforce acquired Mulesoft, and Cloudera and Hortonworks merged; all were other open source leaders. I must confess, I had never heard of some of these companies, but I'm starting to believe what MarketWatch said following the IBM announcement: "open source has truly arrived." What exactly that means, especially for healthcare, I'm not sure, but it's worth exploring. IBM is paying $34b for Red Hat.

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Imagining a Future American Culture of Health

One of the most thought-provoking articles I've read lately is Tom Vanderbilt's Why Futurism Has a Cultural Blindspot in Nautilus. In it, he discusses how our technological visions of the future seem to do much better on predicting the technology of that future than they do the culture in which they will be used. As he says, "But when it comes to culture we tend to believe not that the future will be very different than the present day, but that it will be roughly the same. Try to imagine yourself at some future date.... Chances are, that person resembles you now."

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Apple Watch Leaves Patients Connected with Nowhere To Go

The highly anticipated unveiling of the Apple Watch Series 4 caused a news and social media sensation. Apple coined the iconic timepiece as the "guardian of your health", with health tracking functionalities such as the ability to detect atrial fibrillation (AFib) by a self-performed electrocardiogram (ECG). But from patients' and carepartners' perspectives, there is a long road to a universally accessible, seamlessly implemented, mass-adoption, and meaningful use for this wearable technology...Unfortunately, the vast majority of concerns in the public domain haven't emphasized the risks to health due to poor implementation, integration, and adoption strategies of digital tools and wearables.

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National Biodefense Strategy: Protecting the Nation Against all Biological Threats

Today, the White House and four federal departments unveiled a comprehensive National Biodefense Strategy to make America safer against modern biological threats to the United States. In the 21st century, biological threats are increasingly complex and dangerous, and that demands that we act with urgency and singular effort to save lives and protect Americans. Whether a natural outbreak, an accidental release, or a deliberate attack, biological threats are among the most serious we face, with the potential for significant health, economic and national security impacts. Therefore, promoting our health security is a national security imperative.

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Is China Already in the 21st Century in the Fields of AI for Healthcare and Quantum Computing?

It is 2018 everywhere, but not every country is treating being in the 21st century equally. China is rushing into it, even in healthcare, while the United States is tip-toeing its way towards the future. Especially in healthcare. Ready or not, the future is here...and the U.S. may not be ready...Artificial Intelligence: Yes, the U.S. has been the leader in A.I., with some of the leading universities and tech companies working on it. That may not be enough. A year ago China announced that it intended to be the world leader in A.I. by 2025. The Next Web recently concluded that China's progress since then "remains unchecked." China is far outspending the U.S. on A.I. research and infrastructure, coordinating efforts between government, research institutes, universities, and private companies. Dr. Steven White, a professor at China's Tsinghua University, "likens the country's succeed at all costs AI program to Russia's Sputnik moment." We have yet to have that wake-up call...

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The (Awesome) Economics of Open Source

Successful open source software companies "discover" markets where transaction costs far outweigh all other costs, outcompete the proprietary alternatives for all the good reasons that even the economic nay-sayers already concede (e.g., open source is simply a better development model to create and maintain higher-quality, more rapidly innovative software than the finite limits of proprietary software), and then-and this is the important bit-help clients achieve strategic objectives using open source as a platform for their own innovation. With open source, better/faster/cheaper by itself is available for the low, low price of zero dollars. As an open source company, we don't cry about that. Instead, we look at how open source might create a new inflection point that fundamentally changes the economics of existing markets or how it might create entirely new and more valuable markets.

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ONC EHR Reporting Program RFI: A Public Health Perspective

On August 24, 2018, the Office of the National Coordinator for Health Information Technology (ONC) released a Request for Information (RFI) related to the EHR Reporting Program. This RFI is required by the 21st Century Cures Act and its primary purpose is to gather ideas and suggestions related to how ONC might provide better information about Certified EHR Technology (CEHRT). Apparently, the initial intention was to create a "star rating" like the type used in Consumer Reports to use to rate EHRs, but that seems to have been abandoned in favor of some kind of measurement system. But it is far from clear exactly how this would be done.

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CMS Promoting Interoperability Program: A Public Health Perspective

Well, here we go again. The Centers for Medicare and Medicaid Services (CMS) has now released a new Notice of Proposed Rulemaking (NPRM), titled Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program...As this NPRM was released, the CMS Administrator, Seema Verma, published an open letter to doctors which is focused on reducing the burden on doctors so they can spend more time with physicians. HL7 has begun a similar initiative on reducing clinical burden. So the key question is: Does this NPRM go far enough to reduce provider burden in the spirit of Dr. Verma's letter?

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