All Over the Map: Patient Access to Clinical Lab Information

Last September, the Department of Health and Human Services introduced an amendment to the CLIA Program and HIPAA Privacy Rule: Patients’ Access to Test Reports. The rule proposes that patients have unfettered access to clinical lab test reports upon request. While hospitals, clinical labs, and clinicians say they support the proposal, implementation may have its share of problems. Added costs, new processes, privacy protections, and training of lab personnel would be required to comply with the rule.

If the federal rule is adopted, it would override the current model which provides authority to the state health information exchanges who determine accessibility rules. Today, patients’ access to clinical lab information is determined by the states. The rules are, literally, all over the map. I spent the afternoon building a US map in Powerpoint of patient lab data accessibility rules thinking that I would be able to find a rational pattern across the country.

I made a few guesses/presumptions.

• Do states with strong medical lobbies only allow reports to go the the medical provider?
• There are a cluster of states in the Mid-Atlantic (DC, DE, MD, NJ, WV) that already allow patients access to lab data. Has the “open health” movement in DC had any influence on policies in neighboring or nearby states?
• Do states that have large health systems (like Kaiser Permanente in CA, OR, WA, DC, MD, and VA ) with patient portals that share data with patients already have a consistency in policies across states?
• Is there an alignment of data accessibility policies between “blue” states and “red” states?
• Is limited accessibility by patients aligned with strong statewide tort reform and medical malpractice caps?

The answers, for the most part are, “not necessarily.” In politics, it is a mistake to look for rational patterns. Politics aside, looks like the same goes for health care.

Download the map in Powerpoint.

Hot Dog Buns and Health Records

The next time you’re at Costco ogling flat screens and buying a pallet of paper towels, you may also be surprised to learn that Costco members are now eligible to receive incentive pricing on a Costco-branded cloud-based electronic medical record. During my maiden voyage to Costco after arriving in the Bay Area,  I saw a promotion for a Costco-branded EMR, billed as a “Service of the Month.” I was so baffled that I almost crashed into the guy with the cart brimming with hot dog buns. Fortunately, he was more amused than annoyed with me. (When I asked him to pose for this photo, he thought I was crazy.)

I’m not sure if posting marketing materials in Costco’s exit lane is an effective way to target a potential audience of EMR purchasers. However, it demonstrates that EMR marketers will take just about any approach to find a customer.

I picked up the promotional materials on the way out of the store and conducted some research after getting home. I was also surprised to learn that the Costco/EMR partnership was not a first for big-box retailers. Sam’s Club and Dell had a brief affair with another EMR company, eClinicalWorks in 2009, but soon dissolved its partnership due to lack of interest among members.

Given the failed relationship between Dell, Walmart and eClinicalWorks, why is Costco now selling a cloud-based EMR? I asked myself this question. Then I asked this question on Quora and am beginning to collect responses. What’s yours?

Stick Out Your Tongue!

I am lucky enough to share a co-working space with a woman who recently graduated from the American College of Traditional Chinese Medicine. As a result, I get to be the beneficiary of health advice that lies beyond the parameters of traditional Western approaches. Rather than the anatomic or organ systems approaches I’m accustomed to, TCM’s approach is based on “the ancient Chinese perception of humans as microcosms of the larger, surrounding universe—interconnected with nature and subject to its forces. The human body is regarded as an organic entity in which the various organs, tissues, and other parts have distinct functions but are all interdependent. Health and disease relate to balance of the functions.” Searching for an analogy when reading this translation of the Classic Chinese Medicine text Huángdì Nèijīng, I think of an interactive weather map of the body. Turns out that TCM practices also rely heavily on maps of one kind of another.

One of the diagnostic foundations of Traditional Chinese Medicine (TCM) is tongue evaluation. This practice assesses a patient’s general energetic condition. Because the tongue is positioned somewhere between the interior and exterior of the body, it is particularly well suited to detect imbalances. Different areas of a patient’s tongue correspond to the different channels of the body. The color, texture, shape, and regions of the tongue are mapped and provide clues to diagnosis and therapeutic approach and progress. In addition, the tongue is also particularly well suited for photography in a clinical environment, provided the patient is a willing participant. A series of chronological photographs of the patient’s tongue can also provide a vivid picture of their clinical course and the effectiveness of therapies.

Most Common Topographic Representations of the Tongue in Traditional Chinese Medicine

Once a diagnosis is made, TCM practitioners may use acupuncture to treat imbalances in the body. In acupuncture, small thin needles are placed in points along meridians of the body clear blockages and release “qi,” the body’s energy. Of the over 350 points along 12 major meridians of the body can also be best represented on a map of the human body. For an acupuncturist to track the points that they use in treatment, they typically record the point in a record by number. However, a visual map of a human body be a great addition to an acupuncture record and would likely be a more efficient means of recording and annotating these procedures.

A Model of Acupunture Points in the Human Body

TCM practice, along with a litany of other Western subspecialties can leverage files with annotation. This can be a valuable tool in developing a comprehensive and information-rich medical record. This can also be a valuable tool in the education of patients. DrChrono’s FreeDraw feature provides a seamless way to integrate images and annotate. But it’s up to the practitioner to find creative and efficient ways to use it.

Have you found a way to use FreeDraw that we should know about? Let us know.

How Football Ends

Like many in neuroscience, I’ve been thinking about the consequences of traumatic brain injury in football.  In thinking about this, I think I’ve figured out how American-style football will end.  I’m putting the over/under at about 10 years.

The simple explanation of football is this: football is the optimal activity to put the maximum explosive energy a human can develop and deliver it to another human, pause, catch your breath, and do it again.  Football is a game of inches, and so the ball is carried by huge, weight-lifting sprinters who hurl their 200+ pound frames at a line of huge, weight-lifting thugs who try to stop them cold.  I am not anti-football: I played a little football in high school, I played full-pads, full contact intramural football while an undergraduate (an insurance company’s nightmare), and was a rugby player and coach as a graduate student.  My own athletic skill was thuggery.

The problem with this is that repetitive shocks to the brain seem to create pathology in the brain of the protein tau.  Athletes who engage in contact sports have a tendency to suffer from chronic traumatic encephalopathy (CTE), which is identified pathologically by finding dense tangles of tau.  Dense tangles of tau have been found in boxers, football players, professional wrestlers, and soldiers.  There is concern in hockey players and soccer players who head the ball.  One researcher found tau tangles in 8 of 9 donated brains from former NFL players.  This kind of accumulation of tau is associated with young-onset dementia, cognitive change, and mood disorders.

Here’s my scenario for how football ends: a late-teenager in or recently graduated from a private school dies in a car accident, killing himself and several friends.  He played football.  Pathological examination finds signs of CTE.  (This happens.)   His parents claim that early cognitive change resulted in his making the poor choices that resulted in his death, and that this cognitive change was a result of football, and specific techniques that were taught by the coach contributed. (A football player who later studied biomechanics told me that running with high knees imparts a rotational torque on the lineman’s head, rotational motion is most commonly responsible for sports-related concussions.)  The school, fearing a huge court award, settles.

The insurance companies see the writing on the wall: our schools are taking healthy teens with developing brains and encouraging them to play a sport that subjects those brains to trauma, protecting them from abrasion but this and cut all coverage for football programs, fearing the future liability for past programs they covered.  High school football collapses, then football at private universities.  The NFL becomes like WWE — no real feeder program, with serious athletes being raised on other sports.

That’s it.  It’s a simple story that probably happens many times a year. (The rate of motor vehicle-related death in the 15-19 age group is 25/100,000.)  An ambulance-chasing attorney could read the paragraph above and set a google news alert, this post probably contains all the necessary scientific references to pursue a case.  Alternatively, we could change football to make it less dangerous.  Yes, it’s true that humans have been teaching their young males violence for millennia, but only for a couple of decades have we made a science of athletic performance that resulted in such huge, fast, and strong competitors.  Evolution hasn’t kept up.

EHR in the Year 2019

This video was put out my showing a concept of what we might see in the future of technology, super interesting.

Our focus is to bring new technology like this to reality in healthcare.

What do we call this, something like health X.0? Something totally new and interactive.