Author: SOS Blog

Hot, Flat, and Crowded: E.C.E. 101

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Last night we had the pleasure of meeting with the members of the book club to which we belong. This is a group of lively, energetic, intelligent, articulate folks who manage to bring varied and wonderful perspectives to everything we read and discuss. This time, we read Thomas L. Friedman’s Hot, Flat and Crowded: Why We Need a Green Revolution – and How It Can Renew America, his thorough take on climate change, the emergence of the Energy-Climate Era (E.C.E), world petropolitics, and the active role the U.S. must play…NOW. 

First, let me warn you that I am a cynic. I have great wishes for but expect little of other people and am rarely disappointed. I am pleasantly surprised when others take seriously the same things that I do. Fortunately for me, Friedman and others are optimists who believe we are capable of rising to the occasion, creating a clean energy industry, gradually diminishing our use of dirty fuels, and continuing to grow our economy and the global economy all at the same time. His book is a very readable exposition of the issues and what we need to do to get past them.

My primary reaction to Friedman’s book was a major sense of urgency. I am not sure why I spend so much time thinking about and writing about health care reform and electronic medical records (EMRs) when we have so much more important challenges on our doorstep. 

If you do not believe that climate change (and our part in it) is an issue that we must address and take action about sooner rather than later but you are open to learning more, please read this book. If you already accept this premise, you might want to read the book to understand some of the complex issues that make it difficult for us as a country to take action on climate change…and to help determine what our personal next step needs to be. If you do not believe that climate change is happening and that we play a part in it and can do something to solve the problem and you know that your opinion is not going to change, that’s fine…but please just get out of our way while we try to take the difficult steps needed to save the planet, our society and our quality of life.

Friedman quoted from the speech of a twelve-year-old girl to the 1992 Earth Summit in Rio de Janeiro, Brazil. Severn Suzuki is probably the most articulate child advocate of anything I have ever heard. If you have 6:42 to invest, take a look at her speech on YouTube. I have strong emotional reactions to speeches…after I finished crying, I started to think about what I wanted to write and what I want to do. One of the decisions I made is that I will write about this subject regularly…you can expect reports a I become more informed and as we take steps to diminish our personal and business CO2 production.

When I got up this morning to write this article, I first checked my email, then I glanced through the N.Y. Times Today’s Headlines to which I subscribe. Nobel prize-winning economist Paul Krugman decided to write about this same subject for today’s paper. His Op-Ed piece Cassandras of Climate expresses succinctly what Friedman’s book does in detail…the time for us to take major action is NOW.

Small, incremental, easy actions are not likely to be enough to keep our children and grandchildren from experiencing significant discomfort and disruption of their lives…but we must start somewhere. Those of us who accept the scientific opinions of virtually all the climate scientists in the world need to get off our duffs and do something…… NOW.  We must find ways to mobilize all the talents of all our citizens to accomplish the difficult tasks before us.

What are you doing about climate change? Many of you are so much farther along than the rest of us. Please share your experience, ideas and the information you have gleaned to help the rest of us move along.

ICD-10: How will the change affect your life?

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Last week I attended a webinar hosted by Healthcare Informatics about the transition to ICD-10. The webinar was sponsored by Cognizant Technology Solutions and was presented by Janice W. Young from Health Industry Insights and David Hamilton of the Healthcare & Life Science Practice at Cognizant. I am fond of the webinars hosted by Healthcare Informatics. They allow me to gain lots of information about the business of health care in a brief period of time. If you have never attended one, you might find it enjoyable and informative…or extremely anxiety producing, depending upon the topic.

I do not know what the total attendance at this ICD-10 webinar was, but judging by some of the questions asked, the range of participants was huge. The program was aimed at providers, payers (insurance companies), clearinghouses, application vendors, and anyone else who might be affected by the transition from ICD-9 to ICD-10.

Those of you who have no idea what I am talking about might want to start to get some information about this transition. Federal law and HHS rules require that we move from the ICD-9 and CPT-IV to the ICD-10; the deadline for doing so has been moved to October 1, 2013. It will be very interesting to see if we actually get there in time.

We who work in behavioral health have fairly minimal changes to make. The number of diagnostic codes and procedure codes utilized in mental health claim filing (and upcoming behavioral health EMRs) is minuscule compared to the larger health care arena. Software like ours will require minimal modification; but in the general and specialty medical world, the changes will be massive.

Not only are different diagnostic codes required, but the ICD-10 is also a procedural nosology that most of the rest of the world has been using for many years. It allows a much more finely-grained statement of both diagnoses and procedures utilized. Many believe that data obtained from use of the more specific codes is part of what will allow health care cost savings in the future.

The biggest challenges will involve learning the new code sets and translating our current data into something akin to the new codes. I say ‘something akin to’ because there is not a one-to-one mapping from the ICD-9 and CPT-IV to the ICD-10. In fact, the logic of the two systems is quite different. Reports are that CMS is working on a general equivalence map (GEM) between the two systems. Work will continue on testing and tweaking the GEMs for at least three years after the 2013 deadline.

Private market mapping and consulting also exists. Last week, 3M Health Information Systems announced the release of their own mapping tool in a Healthcare Informatics article. While insurers and clearinghouses and hospital systems may make use of these proprietary tools and consulting services, it is likely that the CMS GEMs will work for many of the rest of us.  

I can feel the chill going up and down the spines of professional coders. In just a few years, they will need to be fluent in another language. My niece just finished a program to be a coder and is now studying for her certification. She will be able to just keep right on studying to be ready by 2013. This is not encouraging for someone who has been coding for 30 years, but for a youngster, being newly fluent in ICD-10 will be a very salable skill.

What preparations do you foresee your organization making to get ready for ICD-10? Have you begun to consider this process? Tell us what you think. Just enter your comment by clicking on the title of this article and typing your thoughts in the box below.

Healthcare Reform: Where does mental health fit in?

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I was all set to write an article on various health disorders and their cost. Then I got frustrated. You see, I started reading the original articles upon which the news/opinion articles I was using as reference were based. I found very rapidly that the figures being used in the articles were comparing different things…some of the totals included reporting by consumers of care; some of the totals included services under multiple diagnoses; adding the totals together summed to much more than we spend on all health care all told. I wonder  how much of this misuse of data is occurring during our ongoing national discussion of health care reform. Apples and oranges are not the same and mixing data can result in sloppy conclusions.

On September 10, 2009, the New York Times published an Op-Ed piece by Michael Pollan in which he discusses the costs of health care in the U.S. Big Food vs. Big Insurance discusses the report of the Centers for Disease Control that chronic illnesses account for 70% of all U.S. deaths. The medical bills of those with chronic diseases result in 75% of the health care spending in the U.S. Pollan argues that some of those chronic diseases…obesity, diabetes, cardiovascular disease…are at least partially the result of America’s terrible diet and overeating. Just helping U.S. residents eat better could result in a dramatic reduction in the costs of health care.

Pollan’s position received some confirmation from a podcast of Science Friday on August 28, 2009. How Cooking Made Us Human focused on the hypothesis that humans evolved effectively and developed larger brains because we started cooking our food. Cooking begins breaking food down before it is eaten, so it is easier to digest. Raw food is harder for the body to digest, so one does not get as much nutritional benefit from the food eaten. The result for human evolution was that we were able to take better advantage of the food we ate by cooking it.

The corollary of this hyothesis is that highly processed foods are a big contributor to obesity because they are too easy to digest. The more processed the food, the easier it is for our bodies to use the caloric content of the food. The result is that those whose diets consist largely of processed foods are also heavier. Raw foods are likely good for some who want to lose weight because the body has to work harder to digest them and does not get all the caloric benefit from the food. One can eat more, feel more full, but consume fewer calories.

Pollan’s point that a change in one aspect of our lives could have huge impact on health care spending got me to wondering…is there a mental health issue that is analogous to food/eating related disorders like obesity, diabetes and heart disease?

According to Open Minds On-Line News for September 14, 2009, mental disorders jumped from fifth place among health expenditures in 1996 to third place in 2006 increasing from $35.2 billion to $57.5 billion. The number of people who sought treatment for mental conditions went from 19.3 billion in 1996 to 36.2 billion people in 2006. While the dollars expended per person for behavioral health care are many fewer than for heart conditions ($1591 vs. $3964), perhaps there is a way for behavioral health providers to dramatically reduce costs of care by addressing a single problem.

According to the U.S. Surgeon General, approximately 20% of the U.S. population experience some sort of mental health disorder in any given year. The best estimate is that 16.4% of the population experience some sort of anxiety disorder ranging from Simple Phobia to Post Traumatic Stress Disorder. A full 82% of those who experience a behavioral health disorder suffer from some sort of anxiety disorder.

Is it possible that education on stress reduction, prevention programs aimed at inoculating the U.S. population against anxiety and early treatment of anxiety disorders might decrease the cost of treating the disorders that do emerge? I have heard public health specialists argue that public education and prevention are the only way we will ever get our health care spending under control. I also have read that there is not yet compelling data to demonstrate that preventive care reduces costs at all.  Perhaps we should just focus our attention on the behavioral aspects of the chronic physical diseases? Or maybe behavioral health providers can work in both arenas and assist in dramatically diminishing the costs of health care across the board.

What do you think about this issue? Where should psychologists, psychiatrists, social workers, mental health counselors, community mental health centers and community behavioral organizations focus their energy? Where will our energies be most effectively spent?

Please enter your comments by clicking on the title of this article and typing your comment into the box below.

Yoga: Physical and Mental Health

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Those of you who read this blog regularly might remember that in July I decided to take a more active role in addressing the neck and back pain that is a regular part of my life. I started taking a yoga class. In August, I added a second one. I was all set last week to write my blog article on yoga; then Seth offered to write the week’s entry. I’m glad I waited. You see, I have just learned that September is the first official National Yoga Month, so designated by the U.S. Department of Health and Human Services. Now, I can even make a contribution to the observance by a timely blog entry.

Yoga means union. When we think and talk of the postures that are part of the practice of yoga, we are talking about asana, one of the eight limbs of yoga.  While most of the limbs relate to moral and spiritual development, asana and pranayama are very much physical.

Prana means life/breath. Pranayama is one of the eight limbs of yoga focused on the use of breath control to cause relaxation and alteration of mental state. Those of us who have utilized the teaching of progressive relaxation methods as an adjunct to psychotherapy know that the effect of cleansing breath on mental state is real. Diminishing anxiety and depression so a client can take action on life problems is one of the observed benefits of deep breathing, but the effect of breathing deeply is not just on mental state. Fully oxygenating the blood and relaxing the muscles adequately for the blood to circulate properly speeds healing, reduces stress, and increases the acuity of thinking. 

Recently published researchdemonstrates significant emotional and physical benefit from the practice of Iyengar yoga among a group with chronic lower back pain. www.MedicalNewsToday.com quotes the researchers as saying that “low-back pain is the largest category for medical reimbursements in the US, accounting for 34 billion dollars of medical costs every year.” Diminishing the cost of this care could have significant impact on our health care expenditures. This is one case where the use of complementary/alternative medicine can save all of us some bucks while simultaneously increasing the sense of personal responsibility and mastery for the patient.

Iyengar yoga is one of many schools or styles of yoga practice. It focuses on alignment of the body and balance, two crucial requirements for symptom relief. Practitioners utilize props to facilitate the various yoga postures. The use of chairs and blocks and straps to assist getting into and maintaining the positions makes it possible for just about anyone to practice the Iyengar style of yoga. The study found that those who practiced Iyengar yoga had less pain, less disability and less depression than those who did not. Over the longer term, they also used less medication than those who used traditional medical treatment.

My personal experience is that even minimal (twice a week) practice of yoga has had significant effects on my experience. I have chronic lower back pain, neck and shoulder pain. Practice of yoga has resulted in much improved physical and mental well-being.

  1. The focus on posture and lengthening of the spine has resulted in a day-to-day, minute-to-minute awareness of how I am holding my body. The  positions in which I put myself in my chair at my desk, standing talking to a colleague, having a telephone conversation all result in muscle tightening. Using proper posture allows the muscles and bones to work as they were designed.
  2. My twice a week classes have resulted in considerable strengthening of my muscles. While I bicycle each weekend, my upper body and core muscles get very little workout. The yoga classes take care of that. The core muscles that are crucial to proper alignment of the spine are getting strong enough to do the job adequately.
  3. The focus totally on the physical gets me out of my head for two hours a week. The workout tires the muscles getting me into the ideal state to benefit from the deep relaxation at the end of the class.
  4. I am gaining control over my physical comfort. I had come to a feeling of helplessness to control my pain. That is gone. I now have a much better sense of what I must do and how I must feel to minimize my pain.

While yoga may not be the ideal method of exercise for everyone, it is a wonderful tool that can be used by many. Why not consider exploring some of the benefits for yourself?

Talk with us about your experience with yoga. Your comments are always welcome.

The Devil and Database Encryption

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Most every week I have a call from my credit card company’s security department to see if the recent activity on our account is actually ours. We used to get these calls maybe a couple of times a year, but now it is literally weekly.

A while back our credit card processor for SOS transactions notified us of new, stricter, security measures that we must follow or face the possibility of very substantial penalties. As a result, our customer credit card transactions now live in an encrypted database on a standalone computer that is not connected to our network or the Internet, and authorizes charges through a quaint dial-up modem connection directly to the processor’s system.

Arguably, financial data is a more tempting target for bad guys than most healthcare information, but there is little question that any data stored and moved around via electronic means is vulnerable. HIPAA requires that covered entities, and soon, business associates, take steps to determine the potential risk to the data that is in their systems, and to address the risk through a variety of security measures. These measures run the gamut from locked doors, user access passwords and workstation timeouts, through military-grade data encryption.

I have been thinking a good bit about the last of these: encryption. From CMS’s summary in HIPAA Security Series, Security Standards – Technical Safeguards (page 6-7):

4. ENCRYTION AND DECRYPTION (A) – § 164.312(a)(2)(iv)
Where this implementation specification is a reasonable and appropriate safeguard for a covered entity, the covered entity must:
“Implement a mechanism to encrypt and decrypt electronic protected health information.” (EPHI)

Encryption is a method of converting an original message of regular text into encoded text. The text is encrypted by means of an algorithm (i.e., type of procedure or formula). If information is encrypted, there would be a low probability that anyone other than the receiving party who has the key to the code or access to another confidential process would be able to decrypt (i.e., translate) the text and convert it into plain, comprehensible text.

There are many different encryption methods and technologies to protect  data from being accessed and viewed by unauthorized users.

  • Sample questions for covered entities to consider:
    Which EPHI should be encrypted and decrypted to prevent access by persons or software programs that have not been granted access rights?
  • What encryption and decryption mechanisms are reasonable and  appropriate to implement to prevent access to EPHI by persons or software programs that have not been granted access rights?

Generally, the safeguards you are expected to implement scale proportionately to the risk and the size of your organization. Thinking about the data stored in your billing and EMR systems, you would have to judge the risk to your data as very high if you have the database installed on a notebook computer that is routinely carried around by a staff member. Likewise, data moved across a network over a wi-fi connection would have to be considered as high risk. Even a solo practitioner or two person practice in either of these scenarios would probably be seen as negligent if the data were not protected by available encryption technology.

In the case of the notebook computer, I would think that whole-disk encryption should be in force, as there are likely to be letters, emails, and other sensitive data on the system that would not be protected if just your practice management/EMR database were encrypted.  Microsoft includes its BitLocker encryption system in Windows Server 2008 and the high-end versions of Windows Vista and Windows 7, but there also are many third party disk encryption products that one could use.

Wi-Fi protection means that you should use the best possible wi-fi encryption technology, at this moment, WPA2, coupled with a truly random password. Doing so would prevent virtually anyone “eavesdropping” on your wireless traffic from extracting meaningful information.

The correct path is not so obvious when it comes to encryption of primary databases, especially in the offices of small providers without dedicated IT personnel. Encryption is seeded by a string of characters, similar to a password or passphrase, called an encryption key. It is analogous to the key to your home or office, except that you can’t just break a window or call a locksmith if you lose the key. Good encryption is, for all practical purposes, impossible to crack. So, although the conscientious provider or practice owner’s first impulse probably would be to strongly encrypt, the risk analysis should include the risk of losing the encryption key, and therefore access to all the data stored in the database! The end result would be the same as a catastrophic hard drive failure with no backup — complete data loss and a very serious HIPAA violation.

Database encryption is only workable, therefore, in the presence of a formal, well-considered, bullet-proof procedure for encryption key management. Google that last phrase (“encryption key management”) and you will see that there are government documents several hundred pages in length that describe the procedures that must be followed to assure that  keys are both secure, and also readily available to those who need them.

To encrypt or not to encrypt? Devil or deep blue sea? What do you think? There are simple, keyless encryption schemes that are not terribly secure. Do you use something like that? Do you have a proven procedure for key management that you would be willing to share? You could lock your server in a bank rated vault, but then what if you forget the combination? We are back where we started! Anyone have any answers? Please click the title of this entry and leave us your comments.